MOMETASONE

mometasone furoate 0.1% lotion, 30 mL

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