CARBOMER-980

Body System:

Manner of administration:Application To The Eye

General Schedule

Restricted Benefit

Indication: Severe dry eye syndrome

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 2	Max qty units: 2	# of repeats: 5	DPMQ: $20.50	Max safety net: $21.98	General Patient Charge: $24.77
Available brands
Optifresh eye gel
PAA
Viscotears *Additional charge for this brand is $7.70			DPMQ: $28.20	Max safety net: $21.98	General Patient Charge: $32.47

Body System:

Manner of administration:Application To The Eye

General Schedule

Restricted Benefit

Indication: Severe dry eye syndrome

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 1	Max qty units: 1	# of repeats: 5	DPMQ: $17.14	Max safety net: $18.62	General Patient Charge: $21.41
Available brands
Optifresh eye gel
PAA
Viscotears *Additional charge for this brand is $3.85			DPMQ: $20.99	Max safety net: $18.62	General Patient Charge: $25.26

Body System:

Manner of administration:Application To The Eye

General Schedule

Restricted Benefit

Indication: Severe dry eye syndrome

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 1	Max qty units: 1	# of repeats: 5	DPMQ: $17.14	Max safety net: $18.62	General Patient Charge: $21.41
Available brands
Optifresh eye gel
PAA
Viscotears *Additional charge for this brand is $3.85			DPMQ: $20.99	Max safety net: $18.62	General Patient Charge: $25.26

CARBOMER-980 (14385D)