TILDRAKIZUMAB

TILDRAKIZUMAB (15448C)

Tildrakizumab 100 mg/mL injection, 2 x 1 mL syringes
15448C
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Continuing treatment, Whole body or Continuing treatment, Face, hand, foot - 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: 2 # of repeats: 1 DPMQ: $6,159.64 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ilumya

TILDRAKIZUMAB (15449D)

Tildrakizumab 100 mg/mL injection, 2 x 1 mL syringes
15449D
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Continuing treatment, Face, hand, foot
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: 1 DPMQ: $6,159.64 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ilumya

TILDRAKIZUMAB (15458N)

Tildrakizumab 100 mg/mL injection, 2 x 1 mL syringes
15458N
Body System:
Manner of administration:Injection
General Schedule
Authority Required

Restriction

Indication: Severe chronic plaque psoriasis
Treatment phase: Continuing treatment, Whole body
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: 1 DPMQ: $6,159.64 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Ilumya