MEDROXYPROGESTERONE

MEDROXYPROGESTERONE (13849X)

medroxyprogesterone acetate 10 mg tablet, 30
13849X
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: 2 DPMQ: $27.68 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $13.00
 DPMQ: $40.68 Max safety net: $25.00 General Patient Charge: $38.00

MEDROXYPROGESTERONE (13928C)

medroxyprogesterone acetate 10 mg tablet, 100
13928C
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Endometriosis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 2 DPMQ: $58.80 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $12.98
 DPMQ: $71.78 Max safety net: $25.00 General Patient Charge: $37.98

MEDROXYPROGESTERONE (13956M)

medroxyprogesterone acetate 5 mg tablet, 56
13956M
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: 112 # of repeats: 2 DPMQ: $25.04 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $8.84
 DPMQ: $33.88 Max safety net: $25.00 General Patient Charge: $33.84

MEDROXYPROGESTERONE (2321E)

medroxyprogesterone acetate 10 mg tablet, 30
2321E
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: 2 DPMQ: $21.02 Max safety net: $22.56 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $6.50
 DPMQ: $27.52 Max safety net: $22.56 General Patient Charge: $31.50

MEDROXYPROGESTERONE (2323G)

medroxyprogesterone acetate 5 mg tablet, 56
2323G
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: 56 # of repeats: 2 DPMQ: $19.70 Max safety net: $21.24 General Patient Charge: $24.03
Available brands
Ralovera
Provera
*Additional charge for this brand is $4.42
 DPMQ: $24.12 Max safety net: $21.24 General Patient Charge: $28.45

MEDROXYPROGESTERONE (2722G)

medroxyprogesterone acetate 10 mg tablet, 100
2722G
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Endometriosis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 100 # of repeats: 2 DPMQ: $36.58 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $6.49
 DPMQ: $43.07 Max safety net: $25.00 General Patient Charge: $31.49