NAFARELIN

NAFARELIN (2962X)

nafarelin 200 microgram/actuation nasal spray, 60 actuations
2962X
Body System:
Manner of administration:Nasal
General Schedule
Restricted Benefit

Restriction

Indication: Endometriosis
Treatment phase: Initial treatment, for up to 6 months

Restriction

Indication: Endometriosis
Treatment phase: Subsequent treatment, for up to 6 months
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: 5 DPMQ: $124.63 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Synarel

NAFARELIN (5815C)

nafarelin 200 microgram/actuation nasal spray, 60 actuations
5815C
Body System:
Manner of administration:Nasal
S100 IVF
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5046)

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: 2 # of repeats: 0 DPMQ: $222.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Synarel