MOMETASONE

mometasone furoate 0.1% ointment, 15 g

MOMETASONE (10791Y)

mometasone furoate 0.1% ointment, 15 g
10791Y
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6231)

Indication: Corticosteroid-responsive dermatoses
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 10 Max qty units: 10 # of repeats: 5 DPMQ: $51.38 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
GLENMARK MOMETASONE
Novasone
Zatamil
Elocon
*Additional charge for this brand is $35.30
 DPMQ: $86.68 Max safety net: $25.00 General Patient Charge: $60.30