DOXYCYCLINE

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Restriction

Indication: Severe acne

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 4	Max qty units: 28	# of repeats: 5	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $11.00			DPMQ: $36.32	Max safety net: $25.00	General Patient Charge: $36.00
Mayne Pharma Doxycycline *Additional charge for this brand is $5.72			DPMQ: $31.04	Max safety net: $25.00	General Patient Charge: $30.72

14443E

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Restriction

Indication: Severe acne

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 8	Max qty units: 56	# of repeats: 2	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $22.00			DPMQ: $58.28	Max safety net: $25.00	General Patient Charge: $47.00
Mayne Pharma Doxycycline *Additional charge for this brand is $11.44			DPMQ: $47.72	Max safety net: $25.00	General Patient Charge: $36.44

14484H

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Restriction

Indication: Bronchiectasis

Restriction

Indication: Chronic bronchitis

Restriction

Indication: Severe acne

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 2	Max qty units: 50	# of repeats: 2	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $9.48			DPMQ: $29.66	Max safety net: $21.72	General Patient Charge: $33.99
Mayne Pharma Doxycycline *Additional charge for this brand is $4.82			DPMQ: $25.00	Max safety net: $21.72	General Patient Charge: $29.33

2703G

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Restriction

Indication: Pelvic inflammatory disease

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 4	Max qty units: 28	# of repeats: 0	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $11.00			DPMQ: $36.32	Max safety net: $25.00	General Patient Charge: $36.00
Mayne Pharma Doxycycline *Additional charge for this brand is $5.72			DPMQ: $31.04	Max safety net: $25.00	General Patient Charge: $30.72

2707L

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Restriction

Indication: Bronchiectasis

Restriction

Indication: Chronic bronchitis

Restriction

Indication: Severe acne

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 1	Max qty units: 25	# of repeats: 5	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $4.74			DPMQ: $22.01	Max safety net: $18.81	General Patient Charge: $26.34
Mayne Pharma Doxycycline *Additional charge for this brand is $2.41			DPMQ: $19.68	Max safety net: $18.81	General Patient Charge: $24.01

2708M

Body System:

Manner of administration:Oral

General Schedule

No restrictions

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 1	Max qty units: 7	# of repeats: 1	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $2.75			DPMQ: $19.85	Max safety net: $18.64	General Patient Charge: $24.18
Mayne Pharma Doxycycline *Additional charge for this brand is $1.43			DPMQ: $18.53	Max safety net: $18.64	General Patient Charge: $22.86

3322W

Body System:

Manner of administration:Oral

General Schedule

No restrictions

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 1	Max qty units: 7	# of repeats: 0	DPMQ: -	Max safety net: -	General Patient Charge: -
Available brands
Doryx *Additional charge for this brand is $2.75			DPMQ: $19.85	Max safety net: $18.64	General Patient Charge: $24.18
Mayne Pharma Doxycycline *Additional charge for this brand is $1.43			DPMQ: $18.53	Max safety net: $18.64	General Patient Charge: $22.86

DOXYCYCLINE (10777F)

Restriction

DOXYCYCLINE (14443E)

Restriction

DOXYCYCLINE (14484H)

Restriction

Restriction

Restriction

DOXYCYCLINE (2703G)

Restriction

DOXYCYCLINE (2707L)

Restriction

Restriction

Restriction

DOXYCYCLINE (2708M)

DOXYCYCLINE (3322W)