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: $21.64 Max safety net: $23.12 General Patient Charge: $25.00
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $4.90
 DPMQ: $26.54 Max safety net: $23.12 General Patient Charge: $29.90

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: $45.12 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $19.60
 DPMQ: $64.72 Max safety net: $25.00 General Patient Charge: $44.60

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: $29.48 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $9.80
 DPMQ: $39.28 Max safety net: $25.00 General Patient Charge: $34.80

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: $37.32 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $14.70
 DPMQ: $52.02 Max safety net: $25.00 General Patient Charge: $39.70

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: $52.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $24.50
 DPMQ: $77.48 Max safety net: $25.00 General Patient Charge: $49.50

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: $17.71 Max safety net: $19.19 General Patient Charge: $21.98
Available brands
DIPROVANT
Eleuphrat
Diprosone
*Additional charge for this brand is $2.45
 DPMQ: $20.16 Max safety net: $19.19 General Patient Charge: $24.43