BETAMETHASONE DIPROPIONATE

BETAMETHASONE DIPROPIONATE (10795E)

betamethasone (as dipropionate) 0.05% ointment, 15 g
10795E
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6232)

Indication: Corticosteroid-responsive dermatoses
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: 5 DPMQ: $22.14 Max safety net: $23.68 General Patient Charge: $25.00
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $4.56
 DPMQ: $26.70 Max safety net: $23.68 General Patient Charge: $29.56

BETAMETHASONE DIPROPIONATE (10816G)

betamethasone (as dipropionate) 0.05% ointment, 15 g
10816G
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6263)

Indication: Corticosteroid-responsive dermatoses
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 8 Max qty units: 8 # of repeats: 5 DPMQ: $45.48 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $18.24
 DPMQ: $63.72 Max safety net: $25.00 General Patient Charge: $43.24

BETAMETHASONE DIPROPIONATE (10820L)

betamethasone (as dipropionate) 0.05% ointment, 15 g
10820L
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6246)

Indication: Corticosteroid-responsive dermatoses
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 4 # of repeats: 5 DPMQ: $29.92 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $9.12
 DPMQ: $39.04 Max safety net: $25.00 General Patient Charge: $34.12

BETAMETHASONE DIPROPIONATE (10821M)

betamethasone (as dipropionate) 0.05% ointment, 15 g
10821M
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6218)

Indication: Corticosteroid-responsive dermatoses
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 6 Max qty units: 6 # of repeats: 5 DPMQ: $37.68 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $13.68
 DPMQ: $51.36 Max safety net: $25.00 General Patient Charge: $38.68

BETAMETHASONE DIPROPIONATE (10823P)

betamethasone (as dipropionate) 0.05% ointment, 15 g
10823P
Body System:
Manner of administration:Application
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6231)

Indication: Corticosteroid-responsive dermatoses
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 10 Max qty units: 10 # of repeats: 5 DPMQ: $53.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $22.80
 DPMQ: $76.04 Max safety net: $25.00 General Patient Charge: $47.80

BETAMETHASONE DIPROPIONATE (1119X)

betamethasone (as dipropionate) 0.05% ointment, 15 g
1119X
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: 1 DPMQ: $18.25 Max safety net: $19.79 General Patient Charge: $22.58
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $2.28
 DPMQ: $20.53 Max safety net: $19.79 General Patient Charge: $24.86