PROGESTERONE

PROGESTERONE (10116K)

progesterone 100 mg pessary, 21
10116K
Body System:
Manner of administration:Vaginal
S100 IVF
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4997)

Indication: Assisted Reproductive Technology
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 42 # of repeats: 0 DPMQ: $75.30 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Endometrin

PROGESTERONE (10930G)

progesterone 200 mg pessary, 42
10930G
Body System:
Manner of administration:Vaginal
S100 IVF
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4997)

Indication: Assisted Reproductive Technology
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 42 # of repeats: 0 DPMQ: $88.41 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Progesterone BNM 200
Utrogestan

PROGESTERONE (12465C)

progesterone 200 mg pessary, 15
12465C
Body System:
Manner of administration:Vaginal
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 11673)

Indication: Prevention of preterm birth
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 45 # of repeats: 3 DPMQ: $128.67 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Oripro

PROGESTERONE (12598C)

progesterone 200 mg pessary, 42
12598C
Body System:
Manner of administration:Vaginal
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 11835)

Indication: Prevention of preterm birth
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 42 # of repeats: 3 DPMQ: $95.00 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Progesterone BNM 200
Utrogestan

PROGESTERONE (14730G)

progesterone 100 mg capsule, 30
14730G
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: 30 # of repeats: 5 DPMQ: $43.84 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Progesterone ADVZ 100
Prometrium

PROGESTERONE (14733K)

progesterone 100 mg capsule, 30
14733K
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: The condition must be stable for the prescriber to consider the listed maximum quantity of this medicine suitable for this patient.
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 5 DPMQ: $73.90 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Progesterone ADVZ 100
Prometrium

PROGESTERONE (6366C)

progesterone 8% vaginal gel, 15 applications
6366C
Body System:
Manner of administration:Vaginal
S100 IVF
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5045)

Indication: Assisted Reproductive Technology
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 30 # of repeats: 0 DPMQ: $204.02 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Crinone 8%

PROGESTERONE (9608Q)

progesterone 100 mg pessary, 15
9608Q
Body System:
Manner of administration:Vaginal
S100 IVF
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4997)

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: 45 # of repeats: 0 DPMQ: $158.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Oripro

PROGESTERONE (9609R)

progesterone 200 mg pessary, 15
9609R
Body System:
Manner of administration:Vaginal
S100 IVF
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 4997)

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: 45 # of repeats: 0 DPMQ: $119.34 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Oripro