NATALIZUMAB

NATALIZUMAB (13820J)

natalizumab 150 mg/mL injection, 2 x 1 mL syringes
13820J
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 13625)

Indication: Clinically definite relapsing-remitting multiple sclerosis
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: $637.97 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Tysabri

NATALIZUMAB (13825P)

natalizumab 150 mg/mL injection, 2 x 1 mL syringes
13825P
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 13718)

Indication: Clinically definite relapsing-remitting multiple sclerosis
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: $604.89 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Tysabri

NATALIZUMAB (9505G)

natalizumab 300 mg/15 mL injection, 15 mL vial
9505G
Body System:
Manner of administration:Injection
Public
S100 HSD Public
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 13718)

Indication: Clinically definite relapsing-remitting multiple sclerosis
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: $604.89 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Tysabri

NATALIZUMAB (9624M)

natalizumab 300 mg/15 mL injection, 15 mL vial
9624M
Body System:
Manner of administration:Injection
Private
S100 HSD Private
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 13625)

Indication: Clinically definite relapsing-remitting multiple sclerosis
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: $637.97 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Tysabri