MOMETASONE

MOMETASONE (10804P)

mometasone furoate 0.1% lotion, 30 mL
10804P
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

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: 5 Max qty units: 5 # of repeats: 5 DPMQ: $39.93 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Novasone
Zatamil
Elocon
*Additional charge for this brand is $27.50
 DPMQ: $67.43 Max safety net: $25.00 General Patient Charge: $52.50

MOMETASONE (10805Q)

mometasone furoate 0.1% lotion, 30 mL
10805Q
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6218)

Indication: Corticosteroid-responsive dermatoses

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: 4 Max qty units: 4 # of repeats: 5 DPMQ: $34.72 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Novasone
Zatamil
Elocon
*Additional charge for this brand is $22.00
 DPMQ: $56.72 Max safety net: $25.00 General Patient Charge: $47.00

MOMETASONE (10819K)

mometasone furoate 0.1% lotion, 30 mL
10819K
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

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: $24.26 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Novasone
Zatamil
Elocon
*Additional charge for this brand is $11.00
 DPMQ: $35.26 Max safety net: $25.00 General Patient Charge: $36.00

MOMETASONE (10826T)

mometasone furoate 0.1% lotion, 30 mL
10826T
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

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: 3 Max qty units: 3 # of repeats: 5 DPMQ: $29.49 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Novasone
Zatamil
Elocon
*Additional charge for this brand is $16.50
 DPMQ: $45.99 Max safety net: $25.00 General Patient Charge: $41.50

MOMETASONE (8043H)

mometasone furoate 0.1% lotion, 30 mL
8043H
Body System:
Manner of administration:Application
General Schedule
Restricted Benefit

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: $19.02 Max safety net: $20.50 General Patient Charge: $23.29
Available brands
Novasone
Zatamil
Elocon
*Additional charge for this brand is $5.50
 DPMQ: $24.52 Max safety net: $20.50 General Patient Charge: $28.79