MESALAZINE

MESALAZINE (14838Y)

mesalazine 2 g/60 mL enema, 7 x 60 mL
14838Y
Body System:
Manner of administration:Rectal
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16656)

Indication: Mild to moderate ulcerative colitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 8 Max qty units: 8 # of repeats: 5 DPMQ: $422.40 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Salofalk

MESALAZINE (8616L)

mesalazine 2 g/60 mL enema, 7 x 60 mL
8616L
Body System:
Manner of administration:Rectal
General Schedule
Authority Required (STREAMLINED)

Restriction (Streamlined authority code: 16632)

Indication: Mild to moderate ulcerative colitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 4 # of repeats: 5 DPMQ: $215.60 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Salofalk