GALCANEZUMAB

GALCANEZUMAB (12469G)

galcanezumab 120 mg/mL injection, 1 mL pen device
12469G
Body System:
Manner of administration:Injection
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 14563)

Indication: Treatment-resistant migraine
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: 5 DPMQ: $523.36 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Emgality

GALCANEZUMAB (12478R)

galcanezumab 120 mg/mL injection, 1 mL pen device
12478R
Body System:
Manner of administration:Injection
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16104)

Indication: Treatment-resistant migraine
Treatment phase: Initial treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 2 # of repeats: 1 DPMQ: $1,037.94 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Emgality