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: $199.32 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Puregon 300 IU/0.36 mL

FOLLITROPIN BETA (6336L)

follitropin beta 600 units/0.72 mL injection, 0.72 mL cartridge
6336L
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: 4 Max qty units: 4 # of repeats: 0 DPMQ: $751.04 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Puregon 600 IU/0.72 mL

FOLLITROPIN BETA (6464F)

follitropin beta 900 units/1.08 mL injection, 1.08 mL cartridge
6464F
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: 5 Max qty units: 5 # of repeats: 0 DPMQ: $1,374.69 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Puregon 900 IU/1.08 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: $309.60 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Puregon 300 IU/0.36 mL

FOLLITROPIN BETA (8566W)

follitropin beta 600 units/0.72 mL injection, 0.72 mL cartridge
8566W
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: 2 Max qty units: 2 # of repeats: 5 DPMQ: $399.94 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Puregon 600 IU/0.72 mL

FOLLITROPIN BETA (8871X)

follitropin beta 900 units/1.08 mL injection, 1.08 mL cartridge
8871X
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: 2 Max qty units: 2 # of repeats: 5 DPMQ: $589.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Puregon 900 IU/1.08 mL