AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE

amino acid formula with vitamins and minerals without phenylalanine oral liquid, 30 x 174 mL pouches

AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE (2474F)

amino acid formula with vitamins and minerals without phenylalanine oral liquid, 30 x 174 mL pouches
2474F
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

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: $1,692.60 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
PKU Cooler 20