FOLLITROPIN BETA

FOLLITROPIN BETA (6335K)

follitropin beta 300 units/0.36 mL injection, 0.36 mL cartridge
6335K
Body System:
Manner of administration:Injection
S100 IVF
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 5027)

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: $198.96 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Puregon 300 IU/0.36 mL

FOLLITROPIN BETA (8565T)

follitropin beta 300 units/0.36 mL injection, 0.36 mL cartridge
8565T
Body System:
Manner of administration:Injection
General Schedule
Restricted Benefit

Restriction

Indication: Anovulatory infertility

Restriction

Indication: Infertility
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 3 # of repeats: 5 DPMQ: $318.27 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Puregon 300 IU/0.36 mL