INDOMETACIN

indometacin 25 mg capsule, 50

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