AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE

amino acid formula with vitamins and minerals without phenylalanine oral liquid, 30 x 125 mL pouches

AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE (9021T)

amino acid formula with vitamins and minerals without phenylalanine oral liquid, 30 x 125 mL pouches
9021T
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: $1,673.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
PKU Lophlex LQ 20