PANTOPRAZOLE

PANTOPRAZOLE (14501F)

pantoprazole 20 mg enteric tablet, 30
14501F
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Gastro-oesophageal reflux disease

Restriction

Indication: Scleroderma oesophagus

Restriction

Indication: Zollinger-Ellison syndrome
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: $19.22 Max safety net: $20.70 General Patient Charge: $23.49
Available brands
APO-Pantoprazole
APX-PANTOPRAZOLE
BTC Pantoprazole
Ozpan
PANTOPRAZOLE-WGR
Panthron
Pantoprazole Sandoz
Pantoprazole generichealth
Salpraz
Sozol
Somac
*Additional charge for this brand is $9.90
 DPMQ: $29.12 Max safety net: $20.70 General Patient Charge: $33.39

PANTOPRAZOLE (8399C)

pantoprazole 20 mg enteric tablet, 30
8399C
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Gastro-oesophageal reflux disease

Restriction

Indication: Scleroderma oesophagus

Restriction

Indication: Zollinger-Ellison syndrome
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: $16.50 Max safety net: $17.98 General Patient Charge: $20.77
Available brands
APO-Pantoprazole
APX-PANTOPRAZOLE
BTC Pantoprazole
Ozpan
PANTOPRAZOLE-WGR
Panthron
Pantoprazole Sandoz
Pantoprazole generichealth
Salpraz
Sozol
Somac
*Additional charge for this brand is $4.95
 DPMQ: $21.45 Max safety net: $17.98 General Patient Charge: $25.72