PRAMIPEXOLE

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Parkinson disease

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: $43.36	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
APO-Pramipexole
Simipex 0.25
Simpral
Sifrol *Additional charge for this brand is $7.54			DPMQ: $50.90	Max safety net: $25.00	General Patient Charge: $32.54

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Parkinson disease

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: $28.57	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
APO-Pramipexole
Simipex 0.25
Simpral
Sifrol *Additional charge for this brand is $3.77			DPMQ: $32.34	Max safety net: $25.00	General Patient Charge: $28.77

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Primary severe restless legs 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: 100	# of repeats: 2	DPMQ: $28.57	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
APO-Pramipexole
Simipex 0.25
Simpral
Sifrol *Additional charge for this brand is $3.77			DPMQ: $32.34	Max safety net: $25.00	General Patient Charge: $28.77

PRAMIPEXOLE (14329E)