FOLLITROPIN ALFA

FOLLITROPIN ALFA (6431L)

follitropin alfa 300 units (21.84 microgram)/0.48 mL injection, 0.48 mL pen device
6431L
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: $188.64 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Gonal-f Pen

FOLLITROPIN ALFA (6432M)

follitropin alfa 450 units (32.76 microgram)/0.72 mL injection, 0.72 mL pen device
6432M
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: $278.52 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Gonal-f Pen

FOLLITROPIN ALFA (6433N)

follitropin alfa 900 units (65.52 microgram)/1.44 mL injection, 1.44 mL pen device
6433N
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: $1,686.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Gonal-f Pen

FOLLITROPIN ALFA (8713N)

follitropin alfa 300 units (21.84 microgram)/0.48 mL injection, 0.48 mL pen device
8713N
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: $301.50 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Gonal-f Pen

FOLLITROPIN ALFA (8714P)

follitropin alfa 450 units (32.76 microgram)/0.72 mL injection, 0.72 mL pen device
8714P
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: $447.84 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Gonal-f Pen

FOLLITROPIN ALFA (8715Q)

follitropin alfa 900 units (65.52 microgram)/1.44 mL injection, 1.44 mL pen device
8715Q
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: $748.22 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Gonal-f Pen