DORZOLAMIDE + TIMOLOL

DORZOLAMIDE + TIMOLOL (14386E)

dorzolamide 2% + timolol 0.5% eye drops, 5 mL
14386E
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Elevated intra-ocular pressure
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: $30.90 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cosdor
Vizo-PF Dorzolatim
Cosopt
*Additional charge for this brand is $1.56
 DPMQ: $32.46 Max safety net: $25.00 General Patient Charge: $26.56

DORZOLAMIDE + TIMOLOL (5542Q)

dorzolamide 2% + timolol 0.5% eye drops, 5 mL
5542Q
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Elevated intra-ocular pressure
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: $22.63 Max safety net: $24.17 General Patient Charge: $25.00
Available brands
Cosdor
Vizo-PF Dorzolatim
Cosopt
*Additional charge for this brand is $0.78
 DPMQ: $23.41 Max safety net: $24.17 General Patient Charge: $25.78

DORZOLAMIDE + TIMOLOL (8567X)

dorzolamide 2% + timolol 0.5% eye drops, 5 mL
8567X
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Elevated intra-ocular pressure
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: $22.63 Max safety net: $24.17 General Patient Charge: $25.00
Available brands
Cosdor
Vizo-PF Dorzolatim
Cosopt
*Additional charge for this brand is $0.78
 DPMQ: $23.41 Max safety net: $24.17 General Patient Charge: $25.78