AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE
amino acid formula with vitamins and minerals without phenylalanine oral liquid: powder
for, 30 x 36 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $848.12 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Anamix Junior | |||||
amino acid formula with vitamins and minerals without phenylalanine powder for oral
liquid, 30 x 28 g sachets
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $1,686.12 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Lophlex | |||||
amino acid formula with vitamins and minerals without phenylalanine powder for oral
liquid, 500 g
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 8 | Max qty units: 8 | # of repeats: 5 | DPMQ: $1,098.52 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| XP Maxamum | |||||
amino acid formula with vitamins and minerals without phenylalanine oral semi-solid,
36 x 109 g tubs
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 3 | Max qty units: 3 | # of repeats: 5 | DPMQ: $1,527.27 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Lophlex Sensation 20 | |||||
amino acid formula with vitamins and minerals without phenylalanine oral liquid, 18
x 250 mL
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 5 | Max qty units: 90 | # of repeats: 5 | DPMQ: $830.39 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Easiphen | |||||
amino acid formula with vitamins and minerals without phenylalanine oral liquid, 30
x 125 mL pouches
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $1,686.12 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Lophlex LQ 20 | |||||
amino acid formula with vitamins and minerals without phenylalanine oral liquid, 36
x 125 mL bottles
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $1,027.76 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Anamix Junior LQ | |||||
amino acid formula with vitamins and minerals without phenylalanine oral liquid, 60
x 62.5 mL pouches
Body System:
Manner of administration:Oral
Restriction
Indication: Phenylketonuria
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: $661.46 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| PKU Lophlex LQ 10 | |||||