MESALAZINE

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: 4 Max qty units: 240 # of repeats: 5 DPMQ: $266.04 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pentasa
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: 120 # of repeats: 5 DPMQ: $137.42 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pentasa