MEDROXYPROGESTERONE

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: $59.60 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $13.40
 DPMQ: $73.00 Max safety net: $25.00 General Patient Charge: $38.40

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: $36.69 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $6.70
 DPMQ: $43.39 Max safety net: $25.00 General Patient Charge: $31.70