Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Authority Required (STREAMLINED)

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13100LMPNP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses (PI, CMI)	2	2	5	$34.41	$31.60	$31.60
	Available brands
	Systane

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Authority Required (STREAMLINED)

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13113EOP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses (PI, CMI)	2	2	5	$34.41	$31.60	$31.60
	Available brands
	Systane

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14421BMPNPOP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL (PI, CMI)	2	2	5	$18.51	$19.96	$23.41
	Available brands
	Optixa
	Systanea

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Authority Required (STREAMLINED)

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14520FMPNPOP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses (PI, CMI)	4	4	5	$55.35	$31.60	$31.60
	Available brands
	Systane

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
5524ROP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL (PI, CMI)	1	1	5	$15.98	$17.43	$20.88
	Available brands
	Optixa
	Systanea

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
8676PMPNP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL (PI, CMI)	1	1	5	$15.98	$17.43	$20.88
	Available brands
	Optixa
	Systanea

Source	General Schedule
Body System	SENSORY ORGANS > OPHTHALMOLOGICALS > OTHER OPHTHALMOLOGICALS

Note

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
9219FMP	POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL (PI, CMI)	1	1	11	$15.98	$17.43	$20.88
	Available brands
	Systane SO Products that are in a Supply Only state will be available for dispensing, but not for prescribing. PBS Prescriptions written prior to the Supply Only period are able to be dispensed using either the Supply Only product where available, or an equivalent product as specified on the PBS schedule. Supply onlya