OLANZAPINE

OLANZAPINE (8170B)

olanzapine 2.5 mg tablet, 28
8170B
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4246)

Indication: Schizophrenia

Restriction (Streamlined authority code: 5869)

Indication: Bipolar I disorder
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $17.68 Max safety net: $19.22 General Patient Charge: $22.01
Available brands
APO-OLANZAPINE
Olanzapine RBX
Olanzapine Sandoz
Ozin 2.5
PRYZEX
Zypine
Zyprexa
*Additional charge for this brand is $7.66
 DPMQ: $25.34 Max safety net: $19.22 General Patient Charge: $29.67

OLANZAPINE (8185T)

olanzapine 5 mg tablet, 28
8185T
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4246)

Indication: Schizophrenia

Restriction (Streamlined authority code: 5869)

Indication: Bipolar I disorder
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $18.60 Max safety net: $20.14 General Patient Charge: $22.93
Available brands
APO-OLANZAPINE
Olanzapine RBX
Olanzapine Sandoz
Ozin 5
PRYZEX
Zypine
Zyprexa
*Additional charge for this brand is $9.90
 DPMQ: $28.50 Max safety net: $20.14 General Patient Charge: $32.83

OLANZAPINE (8186W)

olanzapine 7.5 mg tablet, 28
8186W
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4246)

Indication: Schizophrenia

Restriction (Streamlined authority code: 5869)

Indication: Bipolar I disorder
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $19.36 Max safety net: $20.90 General Patient Charge: $23.69
Available brands
APO-OLANZAPINE
Olanzapine RBX
Olanzapine Sandoz
Ozin 7.5
PRYZEX
Zypine
Zyprexa
*Additional charge for this brand is $4.74
 DPMQ: $24.10 Max safety net: $20.90 General Patient Charge: $28.43

OLANZAPINE (8187X)

olanzapine 10 mg tablet, 28
8187X
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4246)

Indication: Schizophrenia

Restriction (Streamlined authority code: 5869)

Indication: Bipolar I disorder
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $20.97 Max safety net: $22.51 General Patient Charge: $25.00
Available brands
APO-OLANZAPINE
Olanzapine RBX
Olanzapine Sandoz
Ozin 10
PRYZEX
Zypine
Zyprexa
*Additional charge for this brand is $4.78
 DPMQ: $25.75 Max safety net: $22.51 General Patient Charge: $29.78

OLANZAPINE (8433W)

olanzapine 5 mg wafer, 28
8433W
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4246)

Indication: Schizophrenia

Restriction (Streamlined authority code: 5869)

Indication: Bipolar I disorder
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: - Max safety net: - General Patient Charge: -
Available brands
Zyprexa Zydis
*Additional charge for this brand is $9.90
 DPMQ: $28.50 Max safety net: $20.14 General Patient Charge: $32.83

OLANZAPINE (8434X)

olanzapine 10 mg wafer, 28
8434X
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4246)

Indication: Schizophrenia

Restriction (Streamlined authority code: 5869)

Indication: Bipolar I disorder
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: - Max safety net: - General Patient Charge: -
Available brands
Zyprexa Zydis
*Additional charge for this brand is $9.66
 DPMQ: $30.63 Max safety net: $22.51 General Patient Charge: $34.66

OLANZAPINE (8952E)

olanzapine 15 mg wafer, 28
8952E
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4246)

Indication: Schizophrenia

Restriction (Streamlined authority code: 5869)

Indication: Bipolar I disorder
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: - Max safety net: - General Patient Charge: -
Available brands
Zyprexa Zydis
*Additional charge for this brand is $11.31
 DPMQ: $35.60 Max safety net: $25.00 General Patient Charge: $36.31

OLANZAPINE (8953F)

olanzapine 20 mg wafer, 28
8953F
Body System:
Manner of administration:Oral
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4246)

Indication: Schizophrenia

Restriction (Streamlined authority code: 5869)

Indication: Bipolar I disorder
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: - Max safety net: - General Patient Charge: -
Available brands
Zyprexa Zydis
*Additional charge for this brand is $11.29
 DPMQ: $38.89 Max safety net: $25.00 General Patient Charge: $36.29

OLANZAPINE (9294E)

olanzapine 210 mg modified release injection [1 vial] (&) inert substance diluent [3 mL vial], 1 pack
9294E
Body System:
Manner of administration:Injection
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4246)

Indication: Schizophrenia
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: $314.64 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Zyprexa Relprevv

OLANZAPINE (9295F)

olanzapine 300 mg modified release injection [1 vial] (&) inert substance diluent [3 mL vial], 1 pack
9295F
Body System:
Manner of administration:Injection
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4246)

Indication: Schizophrenia
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: $506.12 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Zyprexa Relprevv