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
10056GMP	TOCILIZUMAB tocilizumab 200 mg/10 mL injection, 10 mL vial (PI, CMI)	1	1	0	$200.71	$25.00	$25.00
	Available brands
	Actemra

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
10060LMP	TOCILIZUMAB tocilizumab 400 mg/20 mL injection, 20 mL vial (PI, CMI)	1	1	0	$424.25	$25.00	$25.00
	Available brands
	Actemra

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
10064QMP	TOCILIZUMAB tocilizumab 400 mg/20 mL injection, 20 mL vial (PI, CMI)	1	1	0	$399.39	$25.00	$25.00
	Available brands
	Actemra

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
10068XMP	TOCILIZUMAB tocilizumab 80 mg/4 mL injection, 4 mL vial (PI, CMI)	1	1	0	$93.85	$25.00	$25.00
	Available brands
	Actemra

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
10077JMP	TOCILIZUMAB tocilizumab 80 mg/4 mL injection, 4 mL vial (PI, CMI)	1	1	0	$80.97	$25.00	$25.00
	Available brands
	Actemra

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
10079LMP	TOCILIZUMAB tocilizumab 200 mg/10 mL injection, 10 mL vial (PI, CMI)	1	1	0	$217.62	$25.00	$25.00
	Available brands
	Actemra

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

Note

Authority Required (STREAMLINED)

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
11720WMP	TOCILIZUMAB tocilizumab 162 mg/0.9 mL injection, 4 x 0.9 mL syringes (PI, CMI)	1	4	2	$801.70	$25.00	$25.00
	Available brands
	Actemra Subcutaneous Injection

Source	General Schedule
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
11734NMP	TOCILIZUMAB tocilizumab 162 mg/0.9 mL injection, 4 x 0.9 mL pen devices (PI, CMI)	1	4	1	$801.70	$25.00	$25.00
	Available brands
	Actemra ACTPen

Source	General Schedule
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
11748HMP	TOCILIZUMAB tocilizumab 162 mg/0.9 mL injection, 4 x 0.9 mL syringes (PI, CMI)	1	4	1	$801.70	$25.00	$25.00
	Available brands
	Actemra Subcutaneous Injection

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
15138RMP	ADALIMUMAB adalimumab 40 mg/0.4 mL injection, 2 x 0.4 mL pen devices (PI, CMI)	1	2	5	$444.17	$25.00	$25.00
	Available brands
	Hadlimaa
	Humiraa
	Hyrimoza
	Yuflymaa

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
15139TMP	ADALIMUMAB adalimumab 40 mg/0.8 mL injection, 2 x 0.8 mL pen devices (PI, CMI)	1	2	5	$444.17	$25.00	$25.00
	Available brands
	Abriladaa
	Amgevitaa
	Hadlimaa
	Hyrimoza

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
15140WMP	ADALIMUMAB adalimumab 40 mg/0.8 mL injection, 2 x 0.8 mL pen devices (PI, CMI)	1	2	5	$470.82	$25.00	$25.00
	Available brands
	Abriladaa
	Amgevitaa
	Hadlimaa
	Hyrimoza

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
15141XMP	ADALIMUMAB adalimumab 40 mg/0.8 mL injection, 2 x 0.8 mL syringes (PI, CMI)	1	2	5	$444.17	$25.00	$25.00
	Available brands
	Amgevitaa
	Hadlimaa
	Hyrimoza

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
15142YMP	ADALIMUMAB adalimumab 40 mg/0.4 mL injection, 2 x 0.4 mL pen devices (PI, CMI)	1	2	5	$470.82	$25.00	$25.00
	Available brands
	Hadlimaa
	Humiraa
	Hyrimoza
	Yuflymaa

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
15143BMP	ADALIMUMAB adalimumab 20 mg/0.4 mL injection, 0.4 mL syringe (PI, CMI)	2	2	5	$545.68	$25.00	$25.00
	Available brands
	Amgevitaa

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
15154NMP	ADALIMUMAB adalimumab 40 mg/0.8 mL injection, 2 x 0.8 mL syringes (PI, CMI)	1	2	5	$470.82	$25.00	$25.00
	Available brands
	Amgevitaa
	Hadlimaa
	Hyrimoza

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
15156QMP	ADALIMUMAB adalimumab 20 mg/0.2 mL injection, 2 x 0.2 mL syringes (PI, CMI)	1	2	5	$567.42	$25.00	$25.00
	Available brands
	Humiraa

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
15173NMP	ADALIMUMAB adalimumab 20 mg/0.2 mL injection, 2 x 0.2 mL syringes (PI, CMI)	1	2	5	$599.00	$25.00	$25.00
	Available brands
	Humiraa

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
15177TMP	ADALIMUMAB adalimumab 40 mg/0.4 mL injection, 2 x 0.4 mL syringes (PI, CMI)	1	2	5	$444.17	$25.00	$25.00
	Available brands
	Hadlimaa
	Humiraa
	Hyrimoza
	Yuflymaa

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
15178WMP	ADALIMUMAB adalimumab 40 mg/0.4 mL injection, 2 x 0.4 mL syringes (PI, CMI)	1	2	5	$470.82	$25.00	$25.00
	Available brands
	Hadlimaa
	Humiraa
	Hyrimoza
	Yuflymaa

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
15202DMP	ADALIMUMAB adalimumab 20 mg/0.4 mL injection, 0.4 mL syringe (PI, CMI)	2	2	5	$576.38	$25.00	$25.00
	Available brands
	Amgevitaa

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
5733RMP	ETANERCEPT etanercept 50 mg/mL injection, 4 x 1 mL syringes (PI, CMI)	1	1	0	$743.60	$25.00	$25.00
	Available brands
	Enbrela
	Erelzia

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
5734TMP	ETANERCEPT etanercept 25 mg injection [4 vials] (&) inert substance diluent [4 x 1 mL syringes], 1 pack (PI, CMI)	1	1	0	$371.81	$25.00	$25.00
	Available brands
	Enbrel

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
5735WMP	ETANERCEPT etanercept 50 mg/mL injection, 4 x 1 mL pen devices (PI, CMI)	1	1	0	$743.60	$25.00	$25.00
	Available brands
	Enbrela
	Erelzia
	Nepextoa

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
6367DMP	ETANERCEPT etanercept 25 mg injection [4 vials] (&) inert substance diluent [4 x 1 mL syringes], 1 pack (PI, CMI)	1	1	0	$395.56	$25.00	$25.00
	Available brands
	Enbrel

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
9615CMP	ETANERCEPT etanercept 50 mg/mL injection, 4 x 1 mL syringes (PI, CMI)	1	1	0	$782.22	$25.00	$25.00
	Available brands
	Enbrela
	Erelzia

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
9641KMP	ETANERCEPT etanercept 50 mg/mL injection, 4 x 1 mL pen devices (PI, CMI)	1	1	0	$782.22	$25.00	$25.00
	Available brands
	Enbrela
	Erelzia
	Nepextoa

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
9662MMP	ADALIMUMAB adalimumab 40 mg/0.8 mL injection, 2 x 0.8 mL syringes (PI, CMI)	1	2	0	$444.17	$25.00	$25.00
	Available brands
	Amgevitaa
	Hadlimaa
	Hyrimoza

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
9663NMP	ADALIMUMAB adalimumab 40 mg/0.8 mL injection, 2 x 0.8 mL pen devices (PI, CMI)	1	2	0	$444.17	$25.00	$25.00
	Available brands
	Abriladaa
	Amgevitaa
	Hadlimaa
	Hyrimoza

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
9679KMP	ADALIMUMAB adalimumab 40 mg/0.8 mL injection, 2 x 0.8 mL syringes (PI, CMI)	1	2	0	$470.82	$25.00	$25.00
	Available brands
	Amgevitaa
	Hadlimaa
	Hyrimoza

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
9680LMP	ADALIMUMAB adalimumab 40 mg/0.8 mL injection, 2 x 0.8 mL pen devices (PI, CMI)	1	2	0	$470.82	$25.00	$25.00
	Available brands
	Abriladaa
	Amgevitaa
	Hadlimaa
	Hyrimoza