Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13849XMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 10 mg tablet, 30 (PI, CMI)	2	60	2	$27.54	$29.02	$31.60
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $13.40B	2	60	2	$40.94	$29.02	$45.00

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13881NMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 200 mg tablet, 60 (PI, CMI)	2	120	2	$183.46	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13928CMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 10 mg tablet, 100 (PI, CMI)	2	200	2	$59.60	$31.60	$31.60
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $13.40B	2	200	2	$73.00	$31.60	$45.00

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13956MMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 5 mg tablet, 56 (PI, CMI)	2	112	2	$24.76	$26.24	$29.69
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $9.16B	2	112	2	$33.92	$26.24	$38.85

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13961TMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 250 mg tablet, 60 (PI, CMI)	2	120	2	$188.76	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14067JMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 100 mg tablet, 100 (PI, CMI)	2	200	2	$161.94	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > HORMONAL CONTRACEPTIVES FOR SYSTEMIC USE

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14160GMPMWNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 150 mg/mL injection, 1 mL syringe (PI, CMI)	1	1	1	$27.92	$29.40	$31.60
	Available brands
	Depo-Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2316XMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 200 mg tablet, 60 (PI, CMI)	1	60	2	$96.97	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2321EMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 10 mg tablet, 30 (PI, CMI)	1	30	2	$20.66	$22.14	$25.59
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $6.70B	1	30	2	$27.36	$22.14	$32.29

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2323GMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 5 mg tablet, 56 (PI, CMI)	1	56	2	$19.27	$20.75	$24.20
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $4.58B	1	56	2	$23.85	$20.75	$28.78

Source	General Schedule
Body System	GENITO URINARY SYSTEM AND SEX HORMONES > SEX HORMONES AND MODULATORS OF THE GENITAL SYSTEM > PROGESTOGENS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2722GMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 10 mg tablet, 100 (PI, CMI)	1	100	2	$36.69	$31.60	$31.60
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $6.70B	1	100	2	$43.39	$31.60	$38.30

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2725KMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 100 mg tablet, 100 (PI, CMI)	1	100	2	$86.72	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2727MMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 250 mg tablet, 60 (PI, CMI)	1	60	2	$99.49	$31.60	$31.60
	Available brands
	Provera