PRAMIPEXOLE

PRAMIPEXOLE (14324X)

pramipexole dihydrochloride monohydrate 375 microgram modified release tablet, 30
14324X
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $29.42 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER

PRAMIPEXOLE (14325Y)

pramipexole dihydrochloride monohydrate 4.5 mg modified release tablet, 30
14325Y
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $212.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER

PRAMIPEXOLE (14329E)

pramipexole dihydrochloride monohydrate 250 microgram tablet, 100
14329E
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 5 DPMQ: $43.04 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Pramipexole
Simipex 0.25
Simpral
Sifrol
*Additional charge for this brand is $7.30
 DPMQ: $50.34 Max safety net: $25.00 General Patient Charge: $32.30

PRAMIPEXOLE (14360T)

pramipexole dihydrochloride monohydrate 1.5 mg modified release tablet, 30
14360T
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $73.60 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER

PRAMIPEXOLE (14459B)

pramipexole dihydrochloride monohydrate 750 microgram modified release tablet, 30
14459B
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $43.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER

PRAMIPEXOLE (14460C)

pramipexole dihydrochloride monohydrate 3 mg modified release tablet, 30
14460C
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $145.08 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER

PRAMIPEXOLE (14461D)

pramipexole dihydrochloride monohydrate 3.75 mg modified release tablet, 30
14461D
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $176.16 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER

PRAMIPEXOLE (14532W)

pramipexole dihydrochloride monohydrate 1 mg tablet, 100
14532W
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 5 DPMQ: $140.78 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Pramipexole
Sifrol
Simipex 1
Simpral

PRAMIPEXOLE (14556D)

pramipexole dihydrochloride monohydrate 2.25 mg modified release tablet, 30
14556D
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $103.22 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER

PRAMIPEXOLE (3418X)

pramipexole dihydrochloride monohydrate 375 microgram modified release tablet, 30
3418X
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Parkinson disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 30 # of repeats: 5 DPMQ: $21.89 Max safety net: $23.43 General Patient Charge: $25.00
Available brands
SIMIPEX XR
Sifrol ER