IBUPROFEN

IBUPROFEN (3190X)

ibuprofen 400 mg tablet, 30
3190X
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Chronic arthropathies (including osteoarthritis)

Restriction

Indication: Bone pain
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 90 # of repeats: 3 DPMQ: $21.87 Max safety net: $23.35 General Patient Charge: $25.00
Available brands
APO-Ibuprofen 400
WGR-IBUPROFEN 400
Brufen
*Additional charge for this brand is $7.53
 DPMQ: $29.40 Max safety net: $23.35 General Patient Charge: $32.53

IBUPROFEN (3192B)

ibuprofen 400 mg tablet, 30
3192B
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: 0 DPMQ: $16.48 Max safety net: $17.96 General Patient Charge: $20.75
Available brands
APO-Ibuprofen 400
WGR-IBUPROFEN 400
Brufen
*Additional charge for this brand is $2.51
 DPMQ: $18.99 Max safety net: $17.96 General Patient Charge: $23.26

IBUPROFEN (5123P)

ibuprofen 400 mg tablet, 30
5123P
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Chronic arthropathies (including osteoarthritis)

Restriction

Indication: Bone pain
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 90 # of repeats: 0 DPMQ: $21.87 Max safety net: $23.35 General Patient Charge: $25.00
Available brands
APO-Ibuprofen 400
WGR-IBUPROFEN 400
Brufen
*Additional charge for this brand is $7.53
 DPMQ: $29.40 Max safety net: $23.35 General Patient Charge: $32.53

IBUPROFEN (5124Q)

ibuprofen 400 mg tablet, 30
5124Q
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: 0 DPMQ: $16.48 Max safety net: $17.96 General Patient Charge: $20.75
Available brands
APO-Ibuprofen 400
WGR-IBUPROFEN 400
Brufen
*Additional charge for this brand is $2.51
 DPMQ: $18.99 Max safety net: $17.96 General Patient Charge: $23.26

IBUPROFEN (5368M)

ibuprofen 400 mg tablet, 30
5368M
Body System:
Manner of administration:Oral
Palliative Care
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: 3 Max qty units: 90 # of repeats: 3 DPMQ: $21.87 Max safety net: $23.35 General Patient Charge: $25.00
Available brands
APO-Ibuprofen 400
WGR-IBUPROFEN 400
Brufen
*Additional charge for this brand is $7.53
 DPMQ: $29.40 Max safety net: $23.35 General Patient Charge: $32.53