CARBOMER-980

CARBOMER-980 (14385D)

carbomer-980 0.2% eye gel, 10 g
14385D
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

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: $21.08 Max safety net: $22.62 General Patient Charge: $25.00
Available brands
Optifresh eye gel
PAA
Viscotears
*Additional charge for this brand is $7.26
 DPMQ: $28.34 Max safety net: $22.62 General Patient Charge: $32.26

CARBOMER-980 (14420Y)

carbomer-980 0.2% eye drops, 30 x 600 mg ampoules
14420Y
Body System:
Manner of administration:Application To The Eye
General Schedule
Authority Required (STREAMLINED)

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: 6 Max qty units: 6 # of repeats: 5 DPMQ: $48.66 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Viscotears Gel PF

CARBOMER-980 (5503P)

carbomer-980 0.2% eye gel, 10 g
5503P
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

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: $17.72 Max safety net: $19.26 General Patient Charge: $22.05
Available brands
Optifresh eye gel
PAA
Viscotears
*Additional charge for this brand is $3.63
 DPMQ: $21.35 Max safety net: $19.26 General Patient Charge: $25.68

CARBOMER-980 (5504Q)

carbomer-980 0.2% eye drops, 30 x 600 mg ampoules
5504Q
Body System:
Manner of administration:Application To The Eye
General Schedule
Authority Required (STREAMLINED)

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: 3 Max qty units: 3 # of repeats: 5 DPMQ: $31.53 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Viscotears Gel PF

CARBOMER-980 (8384G)

carbomer-980 0.2% eye gel, 10 g
8384G
Body System:
Manner of administration:Application To The Eye
General Schedule
Restricted Benefit

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: $17.72 Max safety net: $19.26 General Patient Charge: $22.05
Available brands
Optifresh eye gel
PAA
Viscotears
*Additional charge for this brand is $3.63
 DPMQ: $21.35 Max safety net: $19.26 General Patient Charge: $25.68

CARBOMER-980 (8578L)

carbomer-980 0.2% eye drops, 30 x 600 mg ampoules
8578L
Body System:
Manner of administration:Application To The Eye
General Schedule
Authority Required (STREAMLINED)

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: 3 Max qty units: 3 # of repeats: 5 DPMQ: $31.53 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Viscotears Gel PF