METHOTREXATE

METHOTREXATE (11295L)

methotrexate 25 mg/0.5 mL injection, 0.5 mL syringe
11295L
Body System:
Manner of administration:Injection
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7488)

Indication: Severe active rheumatoid arthritis

Restriction (Streamlined authority code: 7518)

Indication: Severe psoriasis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 4 # of repeats: 5 DPMQ: $91.20 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Trexject

METHOTREXATE (14103G)

methotrexate 25 mg/0.5 mL injection, 0.5 mL syringe
14103G
Body System:
Manner of administration:Injection
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 15068)

Indication: Severe active juvenile idiopathic arthritis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 4 # of repeats: 5 DPMQ: $91.20 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Trexject