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: $24.56 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $10.24
 DPMQ: $34.80 Max safety net: $25.00 General Patient Charge: $35.24

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: $19.18 Max safety net: $20.66 General Patient Charge: $23.45
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $5.12
 DPMQ: $24.30 Max safety net: $20.66 General Patient Charge: $28.57

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: $35.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $20.48
 DPMQ: $55.76 Max safety net: $25.00 General Patient Charge: $45.48

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: $29.94 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $15.36
 DPMQ: $45.30 Max safety net: $25.00 General Patient Charge: $40.36

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: $40.68 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $25.60
 DPMQ: $66.28 Max safety net: $25.00 General Patient Charge: $50.60

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: $16.48 Max safety net: $17.96 General Patient Charge: $20.75
Available brands
Cortival 1/2
Betnovate 1/2
*Additional charge for this brand is $2.56
 DPMQ: $19.04 Max safety net: $17.96 General Patient Charge: $23.31