RUXOLITINIB
Manner of administration:Oral
Restriction
Indication: High risk and intermediate-2 risk myelofibrosis
Treatment phase: Initial treatment
Restriction
Indication: Intermediate-1 risk myelofibrosis
Treatment phase: Initial 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: 0 | DPMQ: $4,675.43 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jakavi | |||||
Manner of administration:Oral
Restriction (Streamlined authority code: 18324)
Indication: High risk and intermediate-2 risk myelofibrosis
Treatment phase: Continuing treatment
Restriction (Streamlined authority code: 18241)
Indication: Intermediate-1 risk myelofibrosis
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: $4,675.43 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jakavi | |||||
Manner of administration:Oral
Restriction (Streamlined authority code: 13876)
Indication: Grade II to IV acute graft versus host disease (aGVHD)
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: $4,561.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jakavi | |||||
Manner of administration:Oral
Restriction (Streamlined authority code: 13907)
Indication: Grade II to IV acute graft versus host disease (aGVHD)
Treatment phase: Initial 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: 0 | DPMQ: $4,512.50 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jakavi | |||||
Manner of administration:Oral
Restriction (Streamlined authority code: 13906)
Indication: Moderate to severe chronic graft versus host disease (cGVHD)
Treatment phase: Initial treatment
Restriction (Streamlined authority code: 13867)
Indication: Moderate to severe chronic graft versus host disease (cGVHD)
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: $4,675.43 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jakavi | |||||
Manner of administration:Oral
Restriction (Streamlined authority code: 13911)
Indication: Grade II to IV acute graft versus host disease (aGVHD)
Treatment phase: Initial 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: 0 | DPMQ: $4,561.38 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jakavi | |||||
Manner of administration:Oral
Restriction (Streamlined authority code: 13892)
Indication: Grade II to IV acute graft versus host disease (aGVHD)
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: $4,512.50 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jakavi | |||||
Manner of administration:Oral
Restriction
Indication: Polycythemia vera
Treatment phase: Initial treatment
Restriction
Indication: Polycythemia vera
Treatment phase: Balance of Initial treatment - up to 48 weeks
Restriction
Indication: Polycythemia vera
Treatment phase: First continuing treatment
Restriction
Indication: Polycythemia vera
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: $4,675.43 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Jakavi | |||||