Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
10182XMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	1	1	0	$5689.30	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
10183YMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	1	1	5	$5640.63	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
10190HMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	1	1	4	$5640.63	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
10191JMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	1	1	0	$5640.63	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
10192KMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	1	1	4	$5689.30	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Caution

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
10194MMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	1	1	5	$5689.30	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
12840TMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	8	8	0	$45125.04	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
12864CMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	1	1	0	$5689.30	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
12877RMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	6	6	5	$33843.78	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
12896RMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	8	8	0	$45173.71	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Private
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
12899XMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	6	6	5	$33892.47	$31.60	$31.60
	Available brands
	Soliris

Source	S100 HSD Public
Body System	ANTINEOPLASTIC AND IMMUNOMODULATING AGENTS > IMMUNOSUPPRESSANTS > IMMUNOSUPPRESSANTS

Note

Authority Required

Code & Prescriber	Medicinal Product Pack (Name, form & strength and pack size)	Max qty packs	Max qty units	No. of repeats	DPMQ	Max Safety Net	General Patient Charge
12900YMP	ECULIZUMAB eculizumab 300 mg/30 mL injection, 30 mL vial (PI, CMI)	1	1	0	$5640.63	$31.60	$31.60
	Available brands
	Soliris