MESALAZINE

MESALAZINE (13423L)

mesalazine 250 mg enteric tablet, 100
13423L
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Ulcerative colitis

Restriction

Indication: Crohn disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 200 # of repeats: 5 DPMQ: $77.08 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Mesasal

MESALAZINE (1611T)

mesalazine 250 mg enteric tablet, 100
1611T
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Ulcerative colitis

Restriction

Indication: Crohn disease
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 100 # of repeats: 5 DPMQ: $45.43 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Mesasal