VEDOLIZUMAB

VEDOLIZUMAB (12620F)

vedolizumab 108 mg/0.68 mL injection, 2 x 0.68 mL pen devices
12620F
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe Crohn disease
Treatment phase: Balance of supply - subcutaneous form
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 0 DPMQ: $1,663.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Entyvio

VEDOLIZUMAB (12638E)

vedolizumab 108 mg/0.68 mL injection, 2 x 0.68 mL pen devices
12638E
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe Crohn disease
Treatment phase: Initial treatment with subcutaneous form
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 0 DPMQ: $1,663.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Entyvio

VEDOLIZUMAB (12639F)

vedolizumab 108 mg/0.68 mL injection, 2 x 0.68 mL pen devices
12639F
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Moderate to severe ulcerative colitis
Treatment phase: Continuing treatment with subcutaneous form or switching from intravenous form to subcutaneous form
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 5 DPMQ: $1,663.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Entyvio

VEDOLIZUMAB (12644L)

vedolizumab 108 mg/0.68 mL injection, 2 x 0.68 mL pen devices
12644L
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Moderate to severe ulcerative colitis
Treatment phase: Initial treatment with subcutaneous form
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 0 DPMQ: $1,663.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Entyvio

VEDOLIZUMAB (12647P)

vedolizumab 108 mg/0.68 mL injection, 2 x 0.68 mL pen devices
12647P
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Moderate to severe ulcerative colitis
Treatment phase: Balance of supply - subcutaneous form
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 0 DPMQ: $1,663.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Entyvio

VEDOLIZUMAB (12654B)

vedolizumab 108 mg/0.68 mL injection, 2 x 0.68 mL pen devices
12654B
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe Crohn disease
Treatment phase: Continuing treatment with subcutaneous form or switching from intravenous form to subcutaneous form
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 2 # of repeats: 5 DPMQ: $1,663.98 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Entyvio