METHOTREXATE

METHOTREXATE (14643Q)

methotrexate 10 mg tablet, 10
14643Q
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: 10 # of repeats: 5 DPMQ: $21.36 Max safety net: $22.90 General Patient Charge: $25.00
Available brands
Chexate
Methoblastin

METHOTREXATE (1622J)

methotrexate 2.5 mg tablet, 30
1622J
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: 30 # of repeats: 5 DPMQ: $19.45 Max safety net: $20.99 General Patient Charge: $23.78
Available brands
ARX-Methotrexate
Chexate
Methoblastin

METHOTREXATE (1623K)

methotrexate 10 mg tablet, 50
1623K
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Patients requiring doses greater than 20 mg per week
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 50 # of repeats: 2 DPMQ: $49.35 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Methotrexate
Chexate
Methoblastin

METHOTREXATE (2272N)

methotrexate 10 mg tablet, 15
2272N
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: 15 # of repeats: 3 DPMQ: $24.86 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
ARX-Methotrexate
Chexate
Methoblastin