BACLOFEN
Manner of administration:Injection
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: 1 | Max qty units: 10 | # of repeats: 0 | DPMQ: $762.70 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
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Manner of administration:Injection
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: 1 | Max qty units: 10 | # of repeats: 0 | DPMQ: $802.09 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
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Manner of administration:Injection
Restriction (Streamlined authority code: 9562)
Indication: Severe chronic spasticity
Restriction (Streamlined authority code: 9525)
Indication: Severe chronic spasticity
Restriction (Streamlined authority code: 9638)
Indication: Severe chronic spasticity
Restriction (Streamlined authority code: 9606)
Indication: Severe chronic spasticity
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: 0 | DPMQ: $644.72 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Sintetica Baclofen Intrathecal | |||||
Manner of administration:Injection
Restriction (Streamlined authority code: 7152)
Indication: Severe chronic spasticity
Restriction (Streamlined authority code: 7134)
Indication: Severe chronic spasticity
Restriction (Streamlined authority code: 7153)
Indication: Severe chronic spasticity
Restriction (Streamlined authority code: 7148)
Indication: Severe chronic spasticity
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: 0 | DPMQ: $611.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Sintetica Baclofen Intrathecal | |||||
Manner of administration:Oral
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: 200 | # of repeats: 5 | DPMQ: $52.58 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
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Manner of administration:Oral
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: 200 | # of repeats: 5 | DPMQ: $31.54 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
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Manner of administration:Oral
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 100 | # of repeats: 5 | DPMQ: $22.66 | Max safety net: $24.14 | General Patient Charge: $25.00 |
| Available brands | |||||
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Manner of administration:Oral
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 100 | # of repeats: 5 | DPMQ: $33.18 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
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Manner of administration:Injection
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 | |||||
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Manner of administration:Injection
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 | |||||
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