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: $66.24	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $37.90			DPMQ: $104.14	Max safety net: $25.00	General Patient Charge: $62.90

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: $45.48	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $22.74			DPMQ: $68.22	Max safety net: $25.00	General Patient Charge: $47.74

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: $24.74	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $7.58			DPMQ: $32.32	Max safety net: $25.00	General Patient Charge: $32.58

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: $55.88	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $30.32			DPMQ: $86.20	Max safety net: $25.00	General Patient Charge: $55.32

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: $35.12	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $15.16			DPMQ: $50.28	Max safety net: $25.00	General Patient Charge: $40.16

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: $19.55	Max safety net: $21.09	General Patient Charge: $23.88
Available brands
Supriad Cream
Advantan *Additional charge for this brand is $3.79			DPMQ: $23.34	Max safety net: $21.09	General Patient Charge: $27.67