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: $23.90 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Arthrexin
Indocid
*Additional charge for this brand is $1.82
 DPMQ: $25.72 Max safety net: $25.00 General Patient Charge: $26.82