MOMETASONE

mometasone furoate 0.1% cream, 15 g

MOMETASONE (1913Q)

mometasone furoate 0.1% cream, 15 g
1913Q
Body System:
Manner of administration:Application
General Schedule
Restricted Benefit

Restriction

Indication: Corticosteroid-responsive dermatoses
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: 0 DPMQ: $18.10 Max safety net: $19.64 General Patient Charge: $22.43
Available brands
GLENMARK MOMETASONE Alcohol Free
Novasone
Elocon Alcohol Free
*Additional charge for this brand is $3.33
 DPMQ: $21.43 Max safety net: $19.64 General Patient Charge: $25.76