FOLLITROPIN ALFA
follitropin alfa 75 units (5.5 microgram)/0.125 mL injection, 5 x 0.125 mL pen devices
Manner of administration:Injection
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: 3 | Max qty units: 15 | # of repeats: 0 | DPMQ: $329.04 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 75 units (5.5 microgram)/0.125 mL injection, 5 x 0.125 mL pen devices
Manner of administration:Injection
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: 15 | # of repeats: 1 | DPMQ: $356.37 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 300 units (22 microgram)/0.5 mL injection, 5 x 0.5 mL pen devices
Manner of administration:Injection
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: 3 | Max qty units: 15 | # of repeats: 0 | DPMQ: $1,280.37 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 450 units (33 microgram)/0.75 mL injection, 5 x 0.75 mL pen devices
Manner of administration:Injection
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: 3 | Max qty units: 15 | # of repeats: 0 | DPMQ: $1,896.09 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 225 units (16.5 microgram)/0.375 mL injection, 5 x 0.375 mL pen devices
Manner of administration:Injection
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: 3 | Max qty units: 15 | # of repeats: 0 | DPMQ: $969.42 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 150 units (11 microgram)/0.25 mL injection, 5 x 0.25 mL pen devices
Manner of administration:Injection
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: 3 | Max qty units: 15 | # of repeats: 0 | DPMQ: $649.26 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 225 units (16.5 microgram)/0.375 mL injection, 5 x 0.375 mL pen devices
Manner of administration:Injection
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: 15 | # of repeats: 1 | DPMQ: $1,035.45 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||
follitropin alfa 150 units (11 microgram)/0.25 mL injection, 5 x 0.25 mL pen devices
Manner of administration:Injection
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: 15 | # of repeats: 1 | DPMQ: $703.92 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Bemfola | |||||