GOLIMUMAB
Manner of administration:Injection
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: 1 | # of repeats: 5 | DPMQ: $1,014.73 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Simponi | |||||
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)
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: $2,982.90 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Simponi | |||||
Manner of administration:Injection
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: 1 | # of repeats: 1 | DPMQ: $1,014.73 | Max safety net: $25.00 | General Patient Charge: $25.00 |
| Available brands | |||||
| Simponi | |||||