CORIFOLLITROPIN ALFA

CORIFOLLITROPIN ALFA (5816D)

corifollitropin alfa 100 microgram/0.5 mL injection, 0.5 mL syringe
5816D
Body System:
Manner of administration:Injection
S100 IVF
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5009)

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: 1 # of repeats: 0 DPMQ: $393.84 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Elonva

CORIFOLLITROPIN ALFA (5817E)

corifollitropin alfa 150 microgram/0.5 mL injection, 0.5 mL syringe
5817E
Body System:
Manner of administration:Injection
S100 IVF
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5009)

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: 1 # of repeats: 0 DPMQ: $641.03 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Elonva