Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13881NMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 200 mg tablet, 60 (PI, CMI)	2	120	2	$183.13	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
13961TMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 250 mg tablet, 60 (PI, CMI)	2	120	2	$188.43	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14038WMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 500 mg tablet, 30 (PI, CMI)	2	60	2	$188.43	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
14067JMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 100 mg tablet, 100 (PI, CMI)	2	200	2	$161.61	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2316XMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 200 mg tablet, 60 (PI, CMI)	1	60	2	$96.64	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2725KMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 100 mg tablet, 100 (PI, CMI)	1	100	2	$86.39	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2727MMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 250 mg tablet, 60 (PI, CMI)	1	60	2	$99.16	$31.60	$31.60
	Available brands
	Provera

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > ENDOCRINE THERAPY > HORMONES AND RELATED AGENTS

Restricted Benefit

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
2728NMP	MEDROXYPROGESTERONE medroxyprogesterone acetate 500 mg tablet, 30 (PI, CMI)	1	30	2	$99.16	$31.60	$31.60
	Available brands
	Provera