AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE

amino acid formula with vitamins and minerals without phenylalanine oral liquid, 36 x 125 mL bottles

AMINO ACID FORMULA WITH VITAMINS AND MINERALS WITHOUT PHENYLALANINE (9396M)

amino acid formula with vitamins and minerals without phenylalanine oral liquid, 36 x 125 mL bottles
9396M
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: $1,042.08 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
PKU Anamix Junior LQ