OXYBUTYNIN

OXYBUTYNIN (13957N)

oxybutynin hydrochloride 5 mg tablet, 100
13957N
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Detrusor overactivity
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: $31.48 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ditropan

OXYBUTYNIN (13984B)

oxybutynin 3.9 mg/24 hours patch, 8
13984B
Body System:
Manner of administration:Transdermal
General Schedule
Restricted Benefit

Restriction

Indication: Detrusor overactivity
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: $66.46 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Oxytrol

OXYBUTYNIN (8039D)

oxybutynin hydrochloride 5 mg tablet, 100
8039D
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Detrusor overactivity
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: $22.63 Max safety net: $24.11 General Patient Charge: $25.00
Available brands
Ditropan

OXYBUTYNIN (9454N)

oxybutynin 3.9 mg/24 hours patch, 8
9454N
Body System:
Manner of administration:Transdermal
General Schedule
Restricted Benefit

Restriction

Indication: Detrusor overactivity
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: $40.12 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Oxytrol