OXYCODONE

oxycodone hydrochloride 5 mg tablet, 20

OXYCODONE (5195K)

oxycodone hydrochloride 5 mg tablet, 20
5195K
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Severe pain
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 20 # of repeats: 0 DPMQ: $22.20 Max safety net: $23.68 General Patient Charge: $25.00
Available brands
Mayne Pharma Oxycodone IR
Oxycodone Viatris
Oxyndone
ENDONE
*Additional charge for this brand is $2.00
 DPMQ: $24.20 Max safety net: $23.68 General Patient Charge: $27.00