LEVONORGESTREL

LEVONORGESTREL (11909T)

levonorgestrel 19.5 mg intrauterine drug delivery system, 1 system
11909T
Body System:
Manner of administration:Intrauterine
General Schedule
Restricted Benefit

Restriction

Indication: Contraception
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 0 DPMQ: $172.12 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Kyleena

LEVONORGESTREL (14705Y)

levonorgestrel 52 mg intrauterine drug delivery system, 1 system
14705Y
Body System:
Manner of administration:Intrauterine
General Schedule
Restricted Benefit

Restriction

Indication: Contraception
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 0 DPMQ: $192.06 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Mirena

LEVONORGESTREL (2913H)

levonorgestrel 30 microgram tablet, 112 tablets [4 x 28]
2913H
Body System:
Manner of administration:Oral
General Schedule
No restrictions
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 4 # of repeats: 2 DPMQ: $21.49 Max safety net: $22.97 General Patient Charge: $25.00
Available brands
Microlut 28

LEVONORGESTREL (8633J)

levonorgestrel 52 mg intrauterine drug delivery system, 1 system
8633J
Body System:
Manner of administration:Intrauterine
General Schedule
Restricted Benefit

Restriction

Indication: Idiopathic menorrhagia

Restriction

Indication: Idiopathic menorrhagia
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 1 # of repeats: 0 DPMQ: $192.06 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Mirena