IPILIMUMAB

IPILIMUMAB (15230N)

15230N
Body System:
Manner of administration:Injection
Public
Chemotherapy Items for Public Hospital use
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 18071)

Indication: Immunotherapy sensitive advanced or metastatic cancer
Quantities & Cost
Max amount # of repeats DPMA Max safety net General Patient Charge
Max amount: 360 mg # of repeats: 4 DPMA: $42,848.19 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Yervoy
(ipilimumab 50 mg/10 mL injection, 10 mL vial)
Yervoy
(ipilimumab 200 mg/40 mL injection, 40 mL vial)

IPILIMUMAB (15237Y)

15237Y
Body System:
Manner of administration:Injection
Private
Chemotherapy Items for Private Hospital use
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 18071)

Indication: Immunotherapy sensitive advanced or metastatic cancer
Quantities & Cost
Max amount # of repeats DPMA Max safety net General Patient Charge
Max amount: 360 mg # of repeats: 4 DPMA: $43,492.42 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Yervoy
(ipilimumab 50 mg/10 mL injection, 10 mL vial)
Yervoy
(ipilimumab 200 mg/40 mL injection, 40 mL vial)

IPILIMUMAB (2638W)

2638W
Body System:
Manner of administration:Injection
Private
Chemotherapy Items for Private Hospital use
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 18069)

Indication: Stage III melanoma
Quantities & Cost
Max amount # of repeats DPMA Max safety net General Patient Charge
Max amount: 80 mg # of repeats: 1 DPMA: $10,975.78 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Yervoy
(ipilimumab 50 mg/10 mL injection, 10 mL vial)
Yervoy
(ipilimumab 200 mg/40 mL injection, 40 mL vial)

IPILIMUMAB (2641B)

2641B
Body System:
Manner of administration:Injection
Public
Chemotherapy Items for Public Hospital use
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 18069)

Indication: Stage III melanoma
Quantities & Cost
Max amount # of repeats DPMA Max safety net General Patient Charge
Max amount: 80 mg # of repeats: 1 DPMA: $10,780.47 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Yervoy
(ipilimumab 50 mg/10 mL injection, 10 mL vial)
Yervoy
(ipilimumab 200 mg/40 mL injection, 40 mL vial)