FOLLITROPIN ALFA
follitropin alfa 75 units (5.5 microgram)/0.125 mL injection, 5 x 0.125 mL pen devices
Manner of administration:Injection
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: $329.40 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 75 units (5.5 microgram)/0.125 mL injection, 5 x 0.125 mL pen devices
Manner of administration:Injection
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: $346.50 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 300 units (22 microgram)/0.5 mL injection, 5 x 0.5 mL pen devices
Manner of administration:Injection
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: $1,280.73 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 450 units (33 microgram)/0.75 mL injection, 5 x 0.75 mL pen devices
Manner of administration:Injection
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: $1,896.45 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 225 units (16.5 microgram)/0.375 mL injection, 5 x 0.375 mL pen devices
Manner of administration:Injection
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: $969.78 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 150 units (11 microgram)/0.25 mL injection, 5 x 0.25 mL pen devices
Manner of administration:Injection
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: $649.62 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 225 units (16.5 microgram)/0.375 mL injection, 5 x 0.375 mL pen devices
Manner of administration:Injection
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: $1,020.87 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 150 units (11 microgram)/0.25 mL injection, 5 x 0.25 mL pen devices
Manner of administration:Injection
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: $683.70 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 300 units (22 microgram)/0.5 mL injection, 0.5 mL cartridge
Manner of administration:Injection
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: 3 | # of repeats: 5 | DPMQ: $293.31 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
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follitropin alfa 900 units (66 microgram)/1.5 mL injection, 1.5 mL cartridge
Manner of administration:Injection
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: 5 | Max qty units: 5 | # of repeats: 0 | DPMQ: $1,686.64 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
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