FOLLITROPIN ALFA

FOLLITROPIN ALFA (10872F)

follitropin alfa 225 units (16.5 microgram)/0.375 mL injection, 5 x 0.375 mL pen devices
10872F
Body System:
Manner of administration:Injection
S100 IVF
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5027)

Indication: Assisted Reproductive Technology
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 15 # of repeats: 0 DPMQ: $969.42 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bemfola

FOLLITROPIN ALFA (10876K)

follitropin alfa 225 units (16.5 microgram)/0.375 mL injection, 5 x 0.375 mL pen devices
10876K
Body System:
Manner of administration:Injection
General Schedule
Restricted Benefit

Restriction

Indication: Anovulatory infertility

Restriction

Indication: Infertility
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 15 # of repeats: 1 DPMQ: $1,035.45 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Bemfola