METOCLOPRAMIDE

METOCLOPRAMIDE (1207M)

metoclopramide hydrochloride 10 mg tablet, 25
1207M
Body System:
Manner of administration:Oral
General Schedule
No restrictions
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 25 # of repeats: 0 DPMQ: $17.10 Max safety net: $18.64 General Patient Charge: $21.43
Available brands
APO-Metoclopramide
EMEXLON
METOCLOPRAMIDE-WGR
Pramin
Maxolon
*Additional charge for this brand is $3.31
 DPMQ: $20.41 Max safety net: $18.64 General Patient Charge: $24.74

METOCLOPRAMIDE (12507G)

metoclopramide hydrochloride 10 mg tablet, 25
12507G
Body System:
Manner of administration:Oral
Palliative Care
Restricted Benefit

Restriction

Indication: For use in patients receiving palliative care
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 100 # of repeats: 5 DPMQ: $25.32 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Metoclopramide
EMEXLON
METOCLOPRAMIDE-WGR
Pramin
Maxolon
*Additional charge for this brand is $13.24
 DPMQ: $38.56 Max safety net: $25.00 General Patient Charge: $38.24

METOCLOPRAMIDE (5151D)

metoclopramide hydrochloride 10 mg tablet, 25
5151D
Body System:
Manner of administration:Oral
General Schedule
No restrictions
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 25 # of repeats: 0 DPMQ: $17.10 Max safety net: $18.64 General Patient Charge: $21.43
Available brands
APO-Metoclopramide
EMEXLON
METOCLOPRAMIDE-WGR
Pramin
Maxolon
*Additional charge for this brand is $3.31
 DPMQ: $20.41 Max safety net: $18.64 General Patient Charge: $24.74