GLYCERYL TRINITRATE

GLYCERYL TRINITRATE (13490B)

glyceryl trinitrate 5 mg/24 hours patch, 30
13490B
Body System:
Manner of administration:Transdermal
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: 60 # of repeats: 5 DPMQ: $46.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Transiderm-Nitro 25

GLYCERYL TRINITRATE (14371J)

glyceryl trinitrate 5 mg/24 hours patch, 30
14371J
Body System:
Manner of administration:Transdermal
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: 60 # of repeats: 5 DPMQ: $46.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Minitran 5

GLYCERYL TRINITRATE (1515R)

glyceryl trinitrate 5 mg/24 hours patch, 30
1515R
Body System:
Manner of administration:Transdermal
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: 30 # of repeats: 5 DPMQ: $30.01 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Transiderm-Nitro 25

GLYCERYL TRINITRATE (8027L)

glyceryl trinitrate 5 mg/24 hours patch, 30
8027L
Body System:
Manner of administration:Transdermal
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: 30 # of repeats: 5 DPMQ: $30.01 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Minitran 5