ALEMTUZUMAB

ALEMTUZUMAB (10228H)

alemtuzumab 12 mg/1.2 mL injection, 1.2 mL vial
10228H
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 7714)

Indication: Multiple sclerosis
Treatment phase: Initial treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 5 Max qty units: 5 # of repeats: 0 DPMQ: $51,415.45 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Lemtrada

ALEMTUZUMAB (10232M)

alemtuzumab 12 mg/1.2 mL injection, 1.2 mL vial
10232M
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 6847)

Indication: Multiple sclerosis
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 3 # of repeats: 0 DPMQ: $30,849.27 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Lemtrada

ALEMTUZUMAB (10243D)

alemtuzumab 12 mg/1.2 mL injection, 1.2 mL vial
10243D
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 9636)

Indication: Multiple sclerosis
Treatment phase: Initial treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 5 Max qty units: 5 # of repeats: 0 DPMQ: $51,464.33 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Lemtrada

ALEMTUZUMAB (10246G)

alemtuzumab 12 mg/1.2 mL injection, 1.2 mL vial
10246G
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 9589)

Indication: Multiple sclerosis
Treatment phase: Continuing treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 3 Max qty units: 3 # of repeats: 0 DPMQ: $30,898.14 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Lemtrada