LANSOPRAZOLE

LANSOPRAZOLE (14374M)

lansoprazole 15 mg orally disintegrating tablet, 28
14374M
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Gastro-oesophageal reflux disease

Restriction

Indication: Scleroderma oesophagus
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 56 # of repeats: 5 DPMQ: $21.16 Max safety net: $22.64 General Patient Charge: $25.00
Available brands
APO-Lansoprazole ODT
Lansoprazole ODT GH
Zopral ODT
Zoton FasTabs
*Additional charge for this brand is $9.60
 DPMQ: $30.76 Max safety net: $22.64 General Patient Charge: $34.60

LANSOPRAZOLE (9331D)

lansoprazole 15 mg orally disintegrating tablet, 28
9331D
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Gastro-oesophageal reflux disease

Restriction

Indication: Scleroderma oesophagus
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $17.47 Max safety net: $18.95 General Patient Charge: $21.74
Available brands
APO-Lansoprazole ODT
Lansoprazole ODT GH
Zopral ODT
Zoton FasTabs
*Additional charge for this brand is $4.80
 DPMQ: $22.27 Max safety net: $18.95 General Patient Charge: $26.54