FOLLITROPIN BETA

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: $1,374.33 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Puregon 900 IU/1.08 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: $607.34 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Puregon 900 IU/1.08 mL