FOLLITROPIN ALFA
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: $1,686.28 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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follitropin alfa 900 units (66 microgram)/1.5 mL injection, 1.5 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: 2 | Max qty units: 2 | # of repeats: 5 | DPMQ: $748.22 | Max safety net: $25.00 | General Patient Charge: $25.00 |
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