FOLLITROPIN DELTA

FOLLITROPIN DELTA (11414R)

follitropin delta 72 microgram/2.16 mL injection, 2.16 mL pen device
11414R
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: 4 Max qty units: 4 # of repeats: 0 DPMQ: $2,065.52 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Rekovelle

FOLLITROPIN DELTA (11430N)

follitropin delta 12 microgram/0.36 mL injection, 0.36 mL pen device
11430N
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: 5 Max qty units: 5 # of repeats: 0 DPMQ: $445.83 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Rekovelle

FOLLITROPIN DELTA (11431P)

follitropin delta 36 microgram/1.08 mL injection, 1.08 mL pen device
11431P
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: 5 Max qty units: 5 # of repeats: 0 DPMQ: $1,309.23 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Rekovelle