MOMETASONE
Manner of administration:Application
Restriction (Streamlined authority code: 6231)
Indication: Corticosteroid-responsive dermatoses
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 10 | Max qty units: 10 | # of repeats: 5 | DPMQ: $51.74 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $85.04 | Max safety net: $25.00 | General Patient Charge: $58.30 | ||
Manner of administration:Application
Restriction (Streamlined authority code: 6246)
Indication: Corticosteroid-responsive dermatoses
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: $29.32 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $42.64 | Max safety net: $25.00 | General Patient Charge: $38.32 | ||
Manner of administration:Application
Restriction (Streamlined authority code: 6218)
Indication: Corticosteroid-responsive dermatoses
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 6 | Max qty units: 6 | # of repeats: 5 | DPMQ: $36.78 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $56.76 | Max safety net: $25.00 | General Patient Charge: $44.98 | ||
Manner of administration:Application
Restriction (Streamlined authority code: 6263)
Indication: Corticosteroid-responsive dermatoses
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 8 | Max qty units: 8 | # of repeats: 5 | DPMQ: $44.28 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $70.92 | Max safety net: $25.00 | General Patient Charge: $51.64 | ||
Manner of administration:Application
Restriction (Streamlined authority code: 6232)
Indication: Corticosteroid-responsive dermatoses
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 2 | Max qty units: 2 | # of repeats: 5 | DPMQ: $21.84 | Max safety net: $23.38 | General Patient Charge: $25.00 |
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DPMQ: $28.50 | Max safety net: $23.38 | General Patient Charge: $31.66 | ||
Manner of administration:Application
Restriction
Indication: Corticosteroid-responsive dermatoses
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: $18.10 | Max safety net: $19.64 | General Patient Charge: $22.43 |
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DPMQ: $21.43 | Max safety net: $19.64 | General Patient Charge: $25.76 | ||