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
14521GMPNPOP	DEXTRAN-70 + HYPROMELLOSE dextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL (PI, CMI)	2	2	5	$20.99	$22.44	$25.89
	Available brands
	Poly-Tearsa
	Tears Naturalea * Additional charge for this brand is $8.00B	2	2	5	$28.99	$22.44	$33.89

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
1509KMPNP	DEXTRAN-70 + HYPROMELLOSE dextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL (PI, CMI)	1	1	5	$17.22	$18.67	$22.12
	Available brands
	Poly-Tearsa
	Tears Naturalea * Additional charge for this brand is $4.00B	1	1	5	$21.22	$18.67	$26.12

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
5520MOP	DEXTRAN-70 + HYPROMELLOSE dextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL (PI, CMI)	1	1	5	$17.22	$18.67	$22.12
	Available brands
	Poly-Tearsa
	Tears Naturalea * Additional charge for this brand is $4.00B	1	1	5	$21.22	$18.67	$26.12