NICOTINE

NICOTINE (10076H)

nicotine 25 mg/16 hours patch, 28
10076H
Body System:
Manner of administration:Transdermal
General Schedule
Restricted Benefit

Restriction

Indication: Nicotine dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 2 DPMQ: $51.67 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
nicorette 16hr Invisipatch

NICOTINE (3414Q)

nicotine 21 mg/24 hours patch, 28
3414Q
Body System:
Manner of administration:Transdermal
General Schedule
Restricted Benefit

Restriction

Indication: Nicotine dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 2 DPMQ: $51.67 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Nicotinell Step 1

NICOTINE (5465P)

nicotine 21 mg/24 hours patch, 28
5465P
Body System:
Manner of administration:Transdermal
General Schedule
Restricted Benefit

Restriction

Indication: Nicotine dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 2 DPMQ: $51.67 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Nicabate P

NICOTINE (5571F)

nicotine 21 mg/24 hours patch, 28
5571F
Body System:
Manner of administration:Transdermal
General Schedule
Restricted Benefit

Restriction

Indication: Nicotine dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 2 DPMQ: $51.67 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Nicotinell Step 1

NICOTINE (5572G)

nicotine 14 mg/24 hours patch, 28
5572G
Body System:
Manner of administration:Transdermal
General Schedule
Restricted Benefit

Restriction

Indication: Nicotine dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 2 DPMQ: $51.67 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Nicotinell Step 2

NICOTINE (5573H)

nicotine 7 mg/24 hours patch, 28
5573H
Body System:
Manner of administration:Transdermal
General Schedule
Restricted Benefit

Restriction

Indication: Nicotine dependence
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 2 DPMQ: $51.67 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Nicotinell Step 3