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	$80.43	$30.00	$30.00
	Available brands
	Provera

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

Note

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	$19.01	$20.32	$23.61
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $6.70B	1	30	2	$25.71	$20.32	$30.31

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

Note

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	$17.65	$18.96	$22.25
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $4.55B	1	56	2	$22.20	$18.96	$26.80

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
2722GMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 10 mg tablet, 100 (PI, CMI)	1	100	2	$35.04	$30.00	$30.00
	Available brands
	Raloveraa
	Proveraa * Additional charge for this brand is $6.70B	1	100	2	$41.74	$30.00	$36.70

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	$72.17	$30.00	$30.00
	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
2727MMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 250 mg tablet, 60 (PI, CMI)	1	60	2	$97.84	$30.00	$30.00
	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
2728NMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 500 mg tablet, 30 (PI, CMI)	1	30	2	$97.84	$30.00	$30.00
	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
3118DMPNP	MEDROXYPROGESTERONE medroxyprogesterone acetate 150 mg/mL injection, 1 mL vial (PI, CMI)	1	1	1	$26.27	$27.58	$30.00
	Available brands
	Depo-Raloveraa
	Depo-Proveraa * Additional charge for this brand is $7.00B	1	1	1	$33.27	$27.58	$37.00