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: $51.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $86.68 | Max safety net: $25.00 | General Patient Charge: $60.30 | ||
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: $28.84 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $42.96 | Max safety net: $25.00 | General Patient Charge: $39.12 | ||
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: $36.36 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $57.54 | Max safety net: $25.00 | General Patient Charge: $46.18 | ||
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: $43.84 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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DPMQ: $72.08 | Max safety net: $25.00 | General Patient Charge: $53.24 | ||
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: $21.32 | Max safety net: $22.80 | General Patient Charge: $25.00 |
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DPMQ: $28.38 | Max safety net: $22.80 | General Patient Charge: $32.06 | ||
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: $17.55 | Max safety net: $19.03 | General Patient Charge: $21.82 |
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DPMQ: $21.08 | Max safety net: $19.03 | General Patient Charge: $25.35 | ||