POLYETHYLENE GLYCOL-400 + PROPYLENE GLYCOL
polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses
Body System:
Manner of administration:Application To The Eye
Restriction (Streamlined authority code: 6172)
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: $34.68 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Systane | |||||
polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses
Body System:
Manner of administration:Application To The Eye
Restriction (Streamlined authority code: 6172)
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: $34.68 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Systane | |||||
polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL
Body System:
Manner of administration:Application To The Eye
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: $19.46 | Max safety net: $21.00 | General Patient Charge: $23.79 |
| Available brands | |||||
| Systane | |||||
polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 30 x 0.8 mL unit doses
Body System:
Manner of administration:Application To The Eye
Restriction (Streamlined authority code: 15559)
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: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $55.00 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Systane | |||||
polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 28 x 0.8 mL unit doses
Body System:
Manner of administration:Application To The Eye
Restriction (Streamlined authority code: 6172)
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: $33.32 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Systane | |||||
polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 28 x 0.8 mL unit doses
Body System:
Manner of administration:Application To The Eye
Restriction (Streamlined authority code: 15559)
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: 4 | Max qty units: 4 | # of repeats: 5 | DPMQ: $52.28 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Systane | |||||
polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 28 x 0.8 mL unit doses
Body System:
Manner of administration:Application To The Eye
Restriction (Streamlined authority code: 6172)
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: $33.32 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Systane | |||||
polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL
Body System:
Manner of administration:Application To The Eye
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: 1 | Max qty units: 1 | # of repeats: 5 | DPMQ: $16.91 | Max safety net: $18.45 | General Patient Charge: $21.24 |
| Available brands | |||||
| Systane | |||||
polyethylene glycol-400 0.4% + propylene glycol 0.3% eye drops, 15 mL
Body System:
Manner of administration:Application To The Eye
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: 1 | Max qty units: 1 | # of repeats: 5 | DPMQ: $16.91 | Max safety net: $18.45 | General Patient Charge: $21.24 |
| Available brands | |||||
| Systane | |||||