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
13881NMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 200 mg tablet, 60 (PI, CMI)	2	120	2	$183.46	$25.00	$25.00
	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
13961TMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 250 mg tablet, 60 (PI, CMI)	2	120	2	$188.76	$25.00	$25.00
	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
14067JMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 100 mg tablet, 100 (PI, CMI)	2	200	2	$161.94	$25.00	$25.00
	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
2316XMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 200 mg tablet, 60 (PI, CMI)	1	60	2	$96.97	$25.00	$25.00
	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
2725KMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 100 mg tablet, 100 (PI, CMI)	1	100	2	$86.72	$25.00	$25.00
	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
2727MMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 250 mg tablet, 60 (PI, CMI)	1	60	2	$99.49	$25.00	$25.00
	Available brands
	Provera