METRONIDAZOLE

METRONIDAZOLE (1621H)

metronidazole 400 mg tablet, 21
1621H
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Anaerobic infections
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 21 # of repeats: 1 DPMQ: $17.47 Max safety net: $18.95 General Patient Charge: $21.74
Available brands
METRONIDAMED
Metrogyl 400
Flagyl
*Additional charge for this brand is $2.50
 DPMQ: $19.97 Max safety net: $18.95 General Patient Charge: $24.24

METRONIDAZOLE (1630T)

metronidazole 200 mg/5 mL oral liquid, 100 mL
1630T
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: 1 # of repeats: 0 DPMQ: $24.57 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Flagyl S

METRONIDAZOLE (1636D)

metronidazole 200 mg tablet, 21
1636D
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: 21 # of repeats: 1 DPMQ: $16.70 Max safety net: $18.18 General Patient Charge: $20.97
Available brands
METRONIDAMED
Metrogyl 200

METRONIDAZOLE (1642K)

metronidazole 500 mg suppository, 10
1642K
Body System:
Manner of administration:Rectal
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: 1 # of repeats: 0 DPMQ: $30.75 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Flagyl

METRONIDAZOLE (3339R)

metronidazole 200 mg tablet, 21
3339R
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: 21 # of repeats: 0 DPMQ: $16.70 Max safety net: $18.18 General Patient Charge: $20.97
Available brands
METRONIDAMED
Metrogyl 200

METRONIDAZOLE (3341W)

metronidazole 200 mg/5 mL oral liquid, 100 mL
3341W
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: 1 # of repeats: 0 DPMQ: $24.57 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Flagyl S

METRONIDAZOLE (5155H)

metronidazole 400 mg tablet, 21
5155H
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Anaerobic infections
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 21 # of repeats: 0 DPMQ: $17.47 Max safety net: $18.95 General Patient Charge: $21.74
Available brands
METRONIDAMED
Metrogyl 400
Flagyl
*Additional charge for this brand is $2.50
 DPMQ: $19.97 Max safety net: $18.95 General Patient Charge: $24.24

METRONIDAZOLE (5157K)

metronidazole 500 mg suppository, 10
5157K
Body System:
Manner of administration:Rectal
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: 1 # of repeats: 0 DPMQ: $30.75 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Flagyl