LEVOTHYROXINE

LEVOTHYROXINE (12830G)

levothyroxine sodium 125 microgram tablet, 200
12830G
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $24.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Eltroxin

LEVOTHYROXINE (2173J)

levothyroxine sodium 200 microgram tablet, 200
2173J
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $23.38 Max safety net: $24.92 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $0.96
 DPMQ: $24.34 Max safety net: $24.92 General Patient Charge: $25.96

LEVOTHYROXINE (2174K)

levothyroxine sodium 50 microgram tablet, 200
2174K
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $21.79 Max safety net: $23.33 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $0.96
 DPMQ: $22.75 Max safety net: $23.33 General Patient Charge: $25.96

LEVOTHYROXINE (2175L)

levothyroxine sodium 100 microgram tablet, 200
2175L
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $22.06 Max safety net: $23.60 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $0.96
 DPMQ: $23.02 Max safety net: $23.60 General Patient Charge: $25.96

LEVOTHYROXINE (9287T)

levothyroxine sodium 75 microgram tablet, 200
9287T
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: For prescribing by certain health practitioners
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 200 # of repeats: 1 DPMQ: $21.91 Max safety net: $23.45 General Patient Charge: $25.00
Available brands
APO-Levothyroxine
Eltroxin
Eutroxsig
Levothox
Levothyroxine Lup
Levothyroxine Sandoz
Oroxine
*Additional charge for this brand is $0.97
 DPMQ: $22.88 Max safety net: $23.45 General Patient Charge: $25.97