INDOMETACIN

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Chronic arthropathies (including osteoarthritis)

Indication: Bone pain

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 2	Max qty units: 100	# of repeats: 3	DPMQ: $20.46	Max safety net: $21.94	General Patient Charge: $24.73
Available brands
Arthrexin
Indocid *Additional charge for this brand is $5.04			DPMQ: $25.50	Max safety net: $21.94	General Patient Charge: $29.77

Body System:

Manner of administration:Oral

General Schedule

Restricted Benefit

Indication: Chronic arthropathies (including osteoarthritis)

Indication: Bone pain

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 2	Max qty units: 100	# of repeats: 0	DPMQ: $20.46	Max safety net: $21.94	General Patient Charge: $24.73
Available brands
Arthrexin
Indocid *Additional charge for this brand is $5.04			DPMQ: $25.50	Max safety net: $21.94	General Patient Charge: $29.77

Body System:

Manner of administration:Oral

Palliative Care

Restricted Benefit

Indication: Severe pain

Quantities & Cost

Max qty packs	Max qty units	# of repeats	DPMQ	Max safety net	General Patient Charge
Max qty packs: 2	Max qty units: 100	# of repeats: 3	DPMQ: $20.46	Max safety net: $21.94	General Patient Charge: $24.73
Available brands
Arthrexin
Indocid *Additional charge for this brand is $5.04			DPMQ: $25.50	Max safety net: $21.94	General Patient Charge: $29.77

INDOMETACIN (2454E)