CALCIPOTRIOL + BETAMETHASONE DIPROPIONATE

CALCIPOTRIOL + BETAMETHASONE DIPROPIONATE (11091R)

calcipotriol 0.005% + betamethasone (as dipropionate) 0.05% foam, 60 g
11091R
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: 1 Max qty units: 1 # of repeats: 1 DPMQ: $86.03 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Klarvanta
Enstilar
*Additional charge for this brand is $9.95
 DPMQ: $95.98 Max safety net: $25.00 General Patient Charge: $34.95

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