MESALAZINE

MESALAZINE (11210B)

mesalazine 800 mg enteric tablet, 90
11210B
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Ulcerative colitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 90 # of repeats: 5 DPMQ: $79.44 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Asacol

MESALAZINE (13422K)

mesalazine 800 mg enteric tablet, 90
13422K
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Ulcerative colitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 180 # of repeats: 5 DPMQ: $146.66 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Asacol