METHYLPREDNISOLONE

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: $66.98	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $39.40			DPMQ: $106.38	Max safety net: $25.00	General Patient Charge: $64.40

10835G

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: $45.72	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $23.64			DPMQ: $69.36	Max safety net: $25.00	General Patient Charge: $48.64

10842P

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: $24.44	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $7.88			DPMQ: $32.32	Max safety net: $25.00	General Patient Charge: $32.88

10851D

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: $56.32	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $31.52			DPMQ: $87.84	Max safety net: $25.00	General Patient Charge: $56.52

10855H

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: $35.08	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $15.76			DPMQ: $50.84	Max safety net: $25.00	General Patient Charge: $40.76

8054X

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: 0	DPMQ: $19.11	Max safety net: $20.59	General Patient Charge: $23.38
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $3.94			DPMQ: $23.05	Max safety net: $20.59	General Patient Charge: $27.32