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: $17.28 Max safety net: $18.76 General Patient Charge: $21.55
Available brands
APO-OLANZAPINE
Olanzapine RBX
Olanzapine Sandoz
Ozin 2.5
PRYZEX
Zypine
Zyprexa
*Additional charge for this brand is $7.83
 DPMQ: $25.11 Max safety net: $18.76 General Patient Charge: $29.38

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: $18.20 Max safety net: $19.68 General Patient Charge: $22.47
Available brands
APO-OLANZAPINE
Olanzapine RBX
Olanzapine Sandoz
Ozin 5
PRYZEX
Zypine
Zyprexa
*Additional charge for this brand is $10.17
 DPMQ: $28.37 Max safety net: $19.68 General Patient Charge: $32.64

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: $18.96 Max safety net: $20.44 General Patient Charge: $23.23
Available brands
APO-OLANZAPINE
Olanzapine RBX
Olanzapine Sandoz
Ozin 7.5
PRYZEX
Zypine
Zyprexa
*Additional charge for this brand is $4.87
 DPMQ: $23.83 Max safety net: $20.44 General Patient Charge: $28.10

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: $20.61 Max safety net: $22.09 General Patient Charge: $24.88
Available brands
APO-OLANZAPINE
Olanzapine RBX
Olanzapine Sandoz
Ozin 10
PRYZEX
Zypine
Zyprexa
*Additional charge for this brand is $4.92
 DPMQ: $25.53 Max safety net: $22.09 General Patient Charge: $29.80

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 $10.17
 DPMQ: $28.37 Max safety net: $19.68 General Patient Charge: $32.64

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 $9.95
 DPMQ: $30.56 Max safety net: $22.09 General Patient Charge: $34.83

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 $11.65
 DPMQ: $35.68 Max safety net: $25.00 General Patient Charge: $36.65

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 $11.65
 DPMQ: $39.08 Max safety net: $25.00 General Patient Charge: $36.65

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: $323.50 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: $520.90 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Zyprexa Relprevv