POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL

polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL

POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL (14421B)

polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL
14421B
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

Restriction

Indication: Severe dry eye 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: 2 # of repeats: 5 DPMQ: $18.84 Max safety net: $20.32 General Patient Charge: $23.11
Available brands
Systane