BACLOFEN

BACLOFEN (5617P)

baclofen 10 mg/5 mL intrathecal injection, 5 mL ampoule
5617P
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6925)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 6939)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 6940)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 6911)

Indication: Severe chronic spasticity
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 10 Max qty units: 10 # of repeats: 0 DPMQ: $762.70 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bacthecal
Lioresal Intrathecal

BACLOFEN (6284R)

baclofen 10 mg/5 mL intrathecal injection, 5 mL ampoule
6284R
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 9488)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 9637)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 9489)

Indication: Severe chronic spasticity

Restriction (Streamlined authority code: 9524)

Indication: Severe chronic spasticity
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 10 Max qty units: 10 # of repeats: 0 DPMQ: $802.08 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bacthecal
Lioresal Intrathecal