CALCIPOTRIOL + BETAMETHASONE DIPROPIONATE

calcipotriol 0.005% + betamethasone (as dipropionate) 0.05% foam, 60 g

CALCIPOTRIOL + BETAMETHASONE DIPROPIONATE (13520N)

calcipotriol 0.005% + betamethasone (as dipropionate) 0.05% foam, 60 g
13520N
Body System:
Manner of administration:Application
General Schedule
Restricted Benefit

Restriction

Indication: Chronic stable plaque type psoriasis vulgaris
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: 1 DPMQ: $160.50 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Klarvanta
Enstilar
*Additional charge for this brand is $20.88
 DPMQ: $181.38 Max safety net: $25.00 General Patient Charge: $45.88