INDOMETACIN

INDOMETACIN (2454E)

indometacin 25 mg capsule, 50
2454E
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: 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 (2757D)

indometacin 100 mg suppository, 20
2757D
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: 2 Max qty units: 40 # of repeats: 3 DPMQ: $27.78 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Indocid

INDOMETACIN (5126T)

indometacin 25 mg capsule, 50
5126T
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: 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

INDOMETACIN (5128X)

indometacin 100 mg suppository, 20
5128X
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: 2 Max qty units: 40 # of repeats: 0 DPMQ: $27.78 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Indocid

INDOMETACIN (5377B)

indometacin 25 mg capsule, 50
5377B
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: 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