BETAMETHASONE VALERATE

BETAMETHASONE VALERATE (10794D)

betamethasone (as valerate) 0.05% cream, 15 g
10794D
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: $25.32 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $9.52
 DPMQ: $34.84 Max safety net: $25.00 General Patient Charge: $34.52

BETAMETHASONE VALERATE (10799J)

betamethasone (as valerate) 0.05% cream, 15 g
10799J
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: $19.84 Max safety net: $21.38 General Patient Charge: $24.17
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $4.76
 DPMQ: $24.60 Max safety net: $21.38 General Patient Charge: $28.93

BETAMETHASONE VALERATE (10807T)

betamethasone (as valerate) 0.05% cream, 15 g
10807T
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: $36.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $19.04
 DPMQ: $55.32 Max safety net: $25.00 General Patient Charge: $44.04

BETAMETHASONE VALERATE (10808W)

betamethasone (as valerate) 0.05% cream, 15 g
10808W
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: $30.78 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $14.28
 DPMQ: $45.06 Max safety net: $25.00 General Patient Charge: $39.28

BETAMETHASONE VALERATE (10810Y)

betamethasone (as valerate) 0.05% cream, 15 g
10810Y
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: $41.74 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $23.80
 DPMQ: $65.54 Max safety net: $25.00 General Patient Charge: $48.80

BETAMETHASONE VALERATE (2812B)

betamethasone (as valerate) 0.02% cream, 100 g
2812B
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: 2 Max qty units: 2 # of repeats: 0 DPMQ: $24.70 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Antroquoril
Cortival 1/5
Betnovate 1/5
*Additional charge for this brand is $3.92
 DPMQ: $28.62 Max safety net: $25.00 General Patient Charge: $28.92
Celestone-M
*Additional charge for this brand is $4.78
 DPMQ: $29.48 Max safety net: $25.00 General Patient Charge: $29.78

BETAMETHASONE VALERATE (2813C)

betamethasone (as valerate) 0.05% cream, 15 g
2813C
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: $17.10 Max safety net: $18.64 General Patient Charge: $21.43
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $2.38
 DPMQ: $19.48 Max safety net: $18.64 General Patient Charge: $23.81

BETAMETHASONE VALERATE (4131K)

betamethasone (as valerate) 0.1% cream, 30 g
4131K
Body System:
Manner of administration:Application
Repatriation Pharmaceutical Benefits
No restrictions
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: 2 DPMQ: - Max safety net: - General Patient Charge: -
Available brands
Betnovate DPMQ: $27.87 Max safety net: $7.70 General Patient Charge: $7.70

BETAMETHASONE VALERATE (4132L)

betamethasone (as valerate) 0.1% ointment, 30 g
4132L
Body System:
Manner of administration:Application
Repatriation Pharmaceutical Benefits
No restrictions
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: 2 DPMQ: - Max safety net: - General Patient Charge: -
Available brands
Betnovate DPMQ: $27.87 Max safety net: $7.70 General Patient Charge: $7.70