TOFACITINIB
Manner of administration:Oral
Restriction
Indication: Severe active rheumatoid arthritis
Treatment phase: First continuing treatment
Restriction
Indication: Severe active rheumatoid arthritis
Treatment phase: First continuing treatment - 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: 56 | # of repeats: 5 | DPMQ: $1,155.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xeljanz | |||||
Manner of administration:Oral
Restriction
Indication: Severe active rheumatoid arthritis
Treatment phase: Initial treatment - Initial 1 (new patient)
Restriction
Indication: Severe active rheumatoid arthritis
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break
in biological medicine of less than 24 months)
Restriction
Indication: Severe active rheumatoid arthritis
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological
medicine of more than 24 months)
Restriction
Indication: Severe active rheumatoid arthritis
Treatment phase: Balance of supply - Initial 1 (new patient) or Initial 2 (change or recommencement
of treatment after a break in biological medicine of less than 24 months) or Initial
3 (recommencement of treatment after a break in biological medicine of more than 24
months)
Quantities & Cost
| Max qty packs | Max qty units | # of repeats | DPMQ | Max safety net | General Patient Charge |
|---|---|---|---|---|---|
| Max qty packs: 1 | Max qty units: 56 | # of repeats: 3 | DPMQ: $1,155.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xeljanz | |||||
Manner of administration:Oral
Restriction
Indication: Severe psoriatic arthritis
Treatment phase: Continuing treatment
Restriction
Indication: Severe psoriatic arthritis
Treatment phase: Continuing treatment - 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: 56 | # of repeats: 5 | DPMQ: $1,155.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xeljanz | |||||
Manner of administration:Oral
Restriction
Indication: Severe psoriatic arthritis
Treatment phase: Initial treatment - Initial 1 (new patient)
Restriction
Indication: Severe psoriatic arthritis
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 psoriatic arthritis
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological
medicine of more than 5 years)
Restriction
Indication: Severe psoriatic arthritis
Treatment phase: Initial 1 (new patient) or Initial 2 (change or recommencement of treatment after
a break in biological medicine of less than 5 years) or Initial 3 (recommencement
of treatment after a break in biological medicine of more than 5 years) - 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: 56 | # of repeats: 3 | DPMQ: $1,155.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xeljanz | |||||
Manner of administration:Oral
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 re-commencement 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: Initial 1 (new patient) or Initial 2 (change or recommencement of treatment after
a break in biological medicine of less than 5 years) or Initial 3 (recommencement
of treatment after a break in biological medicine of more than 5 years) - 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: 56 | # of repeats: 3 | DPMQ: $1,155.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xeljanz | |||||
Manner of administration:Oral
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Continuing treatment
Restriction
Indication: Moderate to severe ulcerative colitis
Treatment phase: Continuing treatment - 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: 56 | # of repeats: 5 | DPMQ: $1,155.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xeljanz | |||||
Manner of administration:Oral
Restriction
Indication: Ankylosing spondylitis
Treatment phase: Continuing treatment
Restriction
Indication: Ankylosing spondylitis
Treatment phase: Continuing treatment - 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: 56 | # of repeats: 5 | DPMQ: $1,155.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xeljanz | |||||
Manner of administration:Oral
Restriction
Indication: Ankylosing spondylitis
Treatment phase: Initial treatment - Initial 1 (new patient)
Restriction
Indication: Ankylosing spondylitis
Treatment phase: Initial treatment - Initial 2 (change or recommencement of treatment after a break
in biological medicine of less than 5 years)
Restriction
Indication: Ankylosing spondylitis
Treatment phase: Initial treatment - Initial 3 (recommencement of treatment after a break in biological
medicine of more than 5 years)
Restriction
Indication: Ankylosing spondylitis
Treatment phase: Initial 1 (new patient) or Initial 2 (change or recommencement of treatment after
a break in biological medicine of less than 5 years) or Initial 3 (recommencement
of treatment after a break in biological medicine of more than 5 years) - 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: 56 | # of repeats: 3 | DPMQ: $1,155.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xeljanz | |||||
Manner of administration:Oral
Restriction (Streamlined authority code: 14499)
Indication: Severe active rheumatoid arthritis
Treatment phase: Subsequent 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: 56 | # of repeats: 5 | DPMQ: $1,155.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xeljanz | |||||
Manner of administration:Oral
Restriction (Streamlined authority code: 17707)
Indication: Severe active juvenile idiopathic arthritis
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: 56 | # of repeats: 5 | DPMQ: $1,155.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Xeljanz | |||||