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: 5	Max qty units: 5	# of repeats: 5	DPMQ: $43.29	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Advantan

10833E

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

10834F

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
Metvant
Supriad Ointment
Advantan *Additional charge for this brand is $30.32			DPMQ: $86.20	Max safety net: $25.00	General Patient Charge: $55.32

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

10836H

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
Metvant
Supriad Ointment
Advantan *Additional charge for this brand is $15.16			DPMQ: $50.28	Max safety net: $25.00	General Patient Charge: $40.16

10838K

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: 3	Max qty units: 3	# of repeats: 5	DPMQ: $31.74	Max safety net: $25.00	General Patient Charge: $25.00
Available brands
Advantan

10839L

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
Metvant (Fatty)
Supriad Fatty Ointment
Tanilone (Fatty)
Advantan (Fatty) *Additional charge for this brand is $30.32			DPMQ: $86.20	Max safety net: $25.00	General Patient Charge: $55.32

10840M

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
Metvant (Fatty)
Supriad Fatty Ointment
Tanilone (Fatty)
Advantan (Fatty) *Additional charge for this brand is $15.16			DPMQ: $50.28	Max safety net: $25.00	General Patient Charge: $40.16

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

10843Q

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
Metvant (Fatty)
Supriad Fatty Ointment
Tanilone (Fatty)
Advantan (Fatty) *Additional charge for this brand is $37.90			DPMQ: $104.14	Max safety net: $25.00	General Patient Charge: $62.90