DICLOXACILLIN

DICLOXACILLIN (10790X)

dicloxacillin 500 mg capsule, 24
10790X
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6188)

Indication: Osteomyelitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 48 # of repeats: 1 DPMQ: $30.06 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Dicloxacillin
DICLOXACILLIN VIATRIS 500
Distaph 500
*Additional charge for this brand is $3.80
 DPMQ: $33.86 Max safety net: $25.00 General Patient Charge: $28.80

DICLOXACILLIN (5096F)

dicloxacillin 250 mg capsule, 24
5096F
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Serious staphylococcal infection
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 24 # of repeats: 0 DPMQ: $18.90 Max safety net: $20.44 General Patient Charge: $23.23
Available brands
ARX-Dicloxacillin
DICLOXACILLIN VIATRIS 250
Distaph 250
*Additional charge for this brand is $1.83
 DPMQ: $20.73 Max safety net: $20.44 General Patient Charge: $25.06

DICLOXACILLIN (5097G)

dicloxacillin 500 mg capsule, 24
5097G
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Serious staphylococcal infection
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 24 # of repeats: 0 DPMQ: $22.21 Max safety net: $23.75 General Patient Charge: $25.00
Available brands
ARX-Dicloxacillin
DICLOXACILLIN VIATRIS 500
Distaph 500
*Additional charge for this brand is $1.90
 DPMQ: $24.11 Max safety net: $23.75 General Patient Charge: $26.90

DICLOXACILLIN (8121K)

dicloxacillin 250 mg capsule, 24
8121K
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Serious staphylococcal infection
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 24 # of repeats: 0 DPMQ: $18.90 Max safety net: $20.44 General Patient Charge: $23.23
Available brands
ARX-Dicloxacillin
DICLOXACILLIN VIATRIS 250
Distaph 250
*Additional charge for this brand is $1.83
 DPMQ: $20.73 Max safety net: $20.44 General Patient Charge: $25.06

DICLOXACILLIN (8122L)

dicloxacillin 500 mg capsule, 24
8122L
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Serious staphylococcal infection
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 24 # of repeats: 0 DPMQ: $22.21 Max safety net: $23.75 General Patient Charge: $25.00
Available brands
ARX-Dicloxacillin
DICLOXACILLIN VIATRIS 500
Distaph 500
*Additional charge for this brand is $1.90
 DPMQ: $24.11 Max safety net: $23.75 General Patient Charge: $26.90