Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12940CMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [3 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12941DMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [6 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12942EMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [4 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12949MMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 9 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12950NMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [4 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12951PMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12952QMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [7 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12954TMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 7 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12955WMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [8.3 mL vial], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12956XMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [7 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12957YMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 2 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12958BMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12961EMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 3 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12962FMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 5 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12963GMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12964HMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [8 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12971QMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 4 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12973TMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 6 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12974WMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 8 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12975XMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [6 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12976YMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
12977BMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [3 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13662CMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [7 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13663DMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [8.3 mL vial], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13664EMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 6 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13665FMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 4 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13666GMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [8 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13667HMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 5 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13668JMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [7 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13669KMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13670LMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [3 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13671MMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13672NMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [4 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13673PMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 8 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13674QMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 2 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13675RMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 7 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13676TMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 9 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13677WMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [6 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13678XMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection, 3 x 8.3 mL vials (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13679YMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [6 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13680BMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5.5 mL vial] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13681CMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [5 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13682DMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [3 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma

Source	S100 HSD Public
Body System	MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM > OTHER DRUGS FOR DISORDERS OF THE MUSCULO-SKELETAL SYSTEM

Note

Authority Required

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
13683EMP	ONASEMNOGENE ABEPARVOVEC onasemnogene abeparvovec 20 trillion vector genomes/mL injection [2 x 5.5 mL vials] (&) onasemnogene abeparvovec 20 trillion vector genomes/mL injection [4 x 8.3 mL vials], 1 pack (PI, CMI)	1	1	0	$2527773.87	$31.60	$31.60
	Available brands
	Zolgensma