FREMANEZUMAB

FREMANEZUMAB (12603H)

fremanezumab 225 mg/1.5 mL injection, 1.5 mL syringe
12603H
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: $560.72 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ajovy

FREMANEZUMAB (12611R)

fremanezumab 225 mg/1.5 mL injection, 1.5 mL syringe
12611R
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: 1 Max qty units: 1 # of repeats: 2 DPMQ: $560.72 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ajovy