Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12840TMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	8	8	0	$42,868.80	$25.00	$25.00
	Available brands
	Soliris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12841WMP	RAVULIZUMAB ravulizumab 300 mg/3 mL injection, 3 mL vial (PI, CMI)	1	1	0	$6,623.00	$25.00	$25.00
	Available brands
	Ultomiris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12856PMP	RAVULIZUMAB ravulizumab 1.1 g/11 mL injection, 11 mL vial (PI, CMI)	1	1	0	$24,105.11	$25.00	$25.00
	Available brands
	Ultomiris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12864CMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	1	1	0	$5,407.48	$25.00	$25.00
	Available brands
	Soliris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12877RMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	6	6	5	$32,151.60	$25.00	$25.00
	Available brands
	Soliris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12883CMP	RAVULIZUMAB ravulizumab 1.1 g/11 mL injection, 11 mL vial (PI, CMI)	1	1	2	$24,105.11	$25.00	$25.00
	Available brands
	Ultomiris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12884DMP	RAVULIZUMAB ravulizumab 300 mg/3 mL injection, 3 mL vial (PI, CMI)	1	1	2	$6,574.12	$25.00	$25.00
	Available brands
	Ultomiris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12895QMP	RAVULIZUMAB ravulizumab 300 mg/3 mL injection, 3 mL vial (PI, CMI)	1	1	2	$6,623.00	$25.00	$25.00
	Available brands
	Ultomiris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12896RMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	8	8	0	$42,917.68	$25.00	$25.00
	Available brands
	Soliris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12897TMP	RAVULIZUMAB ravulizumab 1.1 g/11 mL injection, 11 mL vial (PI, CMI)	1	1	2	$24,153.99	$25.00	$25.00
	Available brands
	Ultomiris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12898WMP	RAVULIZUMAB ravulizumab 300 mg/3 mL injection, 3 mL vial (PI, CMI)	1	1	0	$6,574.12	$25.00	$25.00
	Available brands
	Ultomiris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12899XMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	6	6	5	$32,200.50	$25.00	$25.00
	Available brands
	Soliris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12900YMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	1	1	0	$5,358.60	$25.00	$25.00
	Available brands
	Soliris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

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
12901BMP	RAVULIZUMAB ravulizumab 1.1 g/11 mL injection, 11 mL vial (PI, CMI)	1	1	0	$24,153.99	$25.00	$25.00
	Available brands
	Ultomiris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

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
13175KMP	PEGCETACOPLAN pegcetacoplan 1.08 g/20 mL injection, 20 mL vial (PI, CMI)	1	1	0	$4,343.86	$25.00	$25.00
	Available brands
	Empaveli

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

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
13180QMP	PEGCETACOPLAN pegcetacoplan 1.08 g/20 mL injection, 20 mL vial (PI, CMI)	1	1	0	$4,343.86	$25.00	$25.00
	Available brands
	Empaveli

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

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
13185YMP	PEGCETACOPLAN pegcetacoplan 1.08 g/20 mL injection, 20 mL vial (PI, CMI)	1	1	5	$4,343.86	$25.00	$25.00
	Available brands
	Empaveli

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

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
13191GMP	PEGCETACOPLAN pegcetacoplan 1.08 g/20 mL injection, 20 mL vial (PI, CMI)	1	1	0	$4,392.74	$25.00	$25.00
	Available brands
	Empaveli

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

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
13196MMP	PEGCETACOPLAN pegcetacoplan 1.08 g/20 mL injection, 20 mL vial (PI, CMI)	1	1	0	$4,392.74	$25.00	$25.00
	Available brands
	Empaveli

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

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
13197NMP	PEGCETACOPLAN pegcetacoplan 1.08 g/20 mL injection, 20 mL vial (PI, CMI)	1	1	5	$4,392.74	$25.00	$25.00
	Available brands
	Empaveli

Source	General Schedule
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

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
15064WMP	IPTACOPAN Iptacopan 200 mg capsule, 56 (PI, CMI)	1	56	5	$38,820.15	$25.00	$25.00
	Available brands
	Fabhalta