LEVONORGESTREL

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 (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