BRIMONIDINE

BRIMONIDINE (14497B)

brimonidine tartrate 0.2% eye drops, 5 mL
14497B
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: The condition must be stable for the prescriber to consider the listed maximum quantity of this medicine suitable for this patient.
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: $30.22 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Enidin
Alphagan
*Additional charge for this brand is $1.90
 DPMQ: $32.12 Max safety net: $25.00 General Patient Charge: $26.90

BRIMONIDINE (5534G)

brimonidine tartrate 0.2% eye drops, 5 mL
5534G
Body System:
Manner of administration:Application To The Eye
General Schedule
No restrictions
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: $22.29 Max safety net: $23.83 General Patient Charge: $25.00
Available brands
Enidin
Alphagan
*Additional charge for this brand is $0.95
 DPMQ: $23.24 Max safety net: $23.83 General Patient Charge: $25.95

BRIMONIDINE (8351M)

brimonidine tartrate 0.2% eye drops, 5 mL
8351M
Body System:
Manner of administration:Application To The Eye
General Schedule
No restrictions
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: $22.29 Max safety net: $23.83 General Patient Charge: $25.00
Available brands
Enidin
Alphagan
*Additional charge for this brand is $0.95
 DPMQ: $23.24 Max safety net: $23.83 General Patient Charge: $25.95