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
15225HMP	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 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
15234TMP	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

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
15235WMP	RAVULIZUMAB ravulizumab 300 mg/3 mL injection, 3 mL vial (PI, CMI)	1	1	1	$6,623.00	$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
15244HMP	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 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
15245JMP	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 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
15246KMP	RAVULIZUMAB ravulizumab 1.1 g/11 mL injection, 11 mL vial (PI, CMI)	1	1	1	$24,105.11	$25.00	$25.00
	Available brands
	Ultomiris

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
15254WMP	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

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
15255XMP	RAVULIZUMAB ravulizumab 300 mg/3 mL injection, 3 mL vial (PI, CMI)	1	1	1	$6,574.12	$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
15258CMP	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

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
15259DMP	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 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
15263HMP	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 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
15264JMP	RAVULIZUMAB ravulizumab 1.1 g/11 mL injection, 11 mL vial (PI, CMI)	1	1	1	$24,153.99	$25.00	$25.00
	Available brands
	Ultomiris