OXYCODONE

OXYCODONE (12311Y)

oxycodone hydrochloride 5 mg capsule, 10
12311Y
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: 10 # of repeats: 0 DPMQ: $25.20 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
OxyNorm

OXYCODONE (12314D)

oxycodone hydrochloride 5 mg capsule, 10
12314D
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: 10 # of repeats: 0 DPMQ: $25.20 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
OxyNorm