MEDROXYPROGESTERONE

MEDROXYPROGESTERONE (13849X)

medroxyprogesterone acetate 10 mg tablet, 30
13849X
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: The condition must be stable for the prescriber to consider the listed maximum quantity of this medicine suitable for this patient.
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 60 # of repeats: 2 DPMQ: $27.54 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $13.40
 DPMQ: $40.94 Max safety net: $25.00 General Patient Charge: $38.40

MEDROXYPROGESTERONE (13928C)

medroxyprogesterone acetate 10 mg tablet, 100
13928C
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Endometriosis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 2 DPMQ: $59.60 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $13.40
 DPMQ: $73.00 Max safety net: $25.00 General Patient Charge: $38.40

MEDROXYPROGESTERONE (13956M)

medroxyprogesterone acetate 5 mg tablet, 56
13956M
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: The condition must be stable for the prescriber to consider the listed maximum quantity of this medicine suitable for this patient.
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 112 # of repeats: 2 DPMQ: $24.76 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $9.16
 DPMQ: $33.92 Max safety net: $25.00 General Patient Charge: $34.16

MEDROXYPROGESTERONE (2321E)

medroxyprogesterone acetate 10 mg tablet, 30
2321E
Body System:
Manner of administration:Oral
General Schedule
No restrictions
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 30 # of repeats: 2 DPMQ: $20.66 Max safety net: $22.14 General Patient Charge: $24.93
Available brands
Ralovera
Provera
*Additional charge for this brand is $6.70
 DPMQ: $27.36 Max safety net: $22.14 General Patient Charge: $31.63

MEDROXYPROGESTERONE (2323G)

medroxyprogesterone acetate 5 mg tablet, 56
2323G
Body System:
Manner of administration:Oral
General Schedule
No restrictions
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 56 # of repeats: 2 DPMQ: $19.27 Max safety net: $20.75 General Patient Charge: $23.54
Available brands
Ralovera
Provera
*Additional charge for this brand is $4.58
 DPMQ: $23.85 Max safety net: $20.75 General Patient Charge: $28.12

MEDROXYPROGESTERONE (2722G)

medroxyprogesterone acetate 10 mg tablet, 100
2722G
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Endometriosis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 100 # of repeats: 2 DPMQ: $36.69 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ralovera
Provera
*Additional charge for this brand is $6.70
 DPMQ: $43.39 Max safety net: $25.00 General Patient Charge: $31.70