METOCLOPRAMIDE

metoclopramide hydrochloride 10 mg tablet, 25

METOCLOPRAMIDE (12507G)

metoclopramide hydrochloride 10 mg tablet, 25
12507G
Body System:
Manner of administration:Oral
Palliative Care
Restricted Benefit

Restriction

Indication: For use in patients receiving palliative care
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 100 # of repeats: 5 DPMQ: $24.56 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
APO-Metoclopramide
EMEXLON
METOCLOPRAMIDE-WGR
Pramin
Maxolon
*Additional charge for this brand is $14.20
 DPMQ: $38.76 Max safety net: $25.00 General Patient Charge: $39.20