VEDOLIZUMAB
Manner of administration:Injection
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial treatment - Initial 1 (new patient)
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break
in biological medicine of less than 5 years)
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological
medicine of more than 5 years)
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Continuing treatment
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Balance of supply
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 0 | DPMQ: $2,802.43 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Entyvio | |||||
Manner of administration:Injection
Restriction
Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 1 (new patient)
Restriction
Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break
in biological medicine of less than 5 years)
Restriction
Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological
medicine of more than 5 years)
Restriction
Indication: Severe Crohn disease
Treatment phase: Continuing treatment
Restriction
Indication: Severe Crohn disease
Treatment phase: Balance of supply
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 0 | DPMQ: $2,802.43 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Entyvio | |||||
Manner of administration:Injection
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial treatment - Initial 1 (new patient)
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break
in biological medicine of less than 5 years)
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological
medicine of more than 5 years)
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Continuing treatment
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Balance of supply
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 0 | DPMQ: $2,851.31 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Entyvio | |||||
Manner of administration:Injection
Restriction
Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 1 (new patient)
Restriction
Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break
in biological medicine of less than 5 years)
Restriction
Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological
medicine of more than 5 years)
Restriction
Indication: Severe Crohn disease
Treatment phase: Continuing treatment
Restriction
Indication: Severe Crohn disease
Treatment phase: Balance of supply
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 0 | DPMQ: $2,851.31 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Entyvio | |||||
Manner of administration:Injection
Restriction
Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 4 (additional dose at week 10)
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 0 | DPMQ: $2,851.31 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Entyvio | |||||
Manner of administration:Injection
Restriction
Indication: Severe Crohn disease
Treatment phase: Initial treatment - Initial 4 (additional dose at week 10)
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 0 | DPMQ: $2,802.43 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Entyvio | |||||
Manner of administration:Injection
Restriction
Indication: Moderate to severe chronic pouchitis
Treatment phase: Initial 1 treatment (new patient)
Restriction
Indication: Moderate to severe chronic pouchitis
Treatment phase: Initial 2 treatment (Recommencement of treatment after a break in biological medicine)
Restriction
Indication: Moderate to severe chronic pouchitis
Treatment phase: Balance of Supply - Initial 1 treatment (new patient) and Initial 2 treatment (recommencement
of treatment after a break in biological medicine)
Restriction
Indication: Moderate to severe chronic pouchitis
Treatment phase: Continuing treatment
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 2 | DPMQ: $2,802.43 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Entyvio | |||||
Manner of administration:Injection
Restriction
Indication: Moderate to severe chronic pouchitis
Treatment phase: Initial 1 treatment (new patient)
Restriction
Indication: Moderate to severe chronic pouchitis
Treatment phase: Initial 2 treatment (Recommencement of treatment after a break in biological medicine)
Restriction
Indication: Moderate to severe chronic pouchitis
Treatment phase: Balance of Supply - Initial 1 treatment (new patient) and Initial 2 treatment (recommencement
of treatment after a break in biological medicine)
Restriction
Indication: Moderate to severe chronic pouchitis
Treatment phase: Continuing treatment
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 1 | # of repeats: 2 | DPMQ: $2,851.31 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Entyvio | |||||