MESALAZINE

MESALAZINE (10254Q)

mesalazine 4 g modified release granules, 30 sachets
10254Q
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Ulcerative colitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 30 # of repeats: 5 DPMQ: $126.66 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pentasa

MESALAZINE (10257W)

mesalazine 3 g modified release granules, 30 sachets
10257W
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Ulcerative colitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 30 # of repeats: 5 DPMQ: $99.92 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Salofalk

MESALAZINE (11210B)

mesalazine 800 mg enteric tablet, 90
11210B
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Ulcerative colitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 90 # of repeats: 5 DPMQ: $78.05 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Asacol

MESALAZINE (11554D)

mesalazine 1 g enteric tablet, 60
11554D
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: 120 # of repeats: 5 DPMQ: $134.78 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Salofalk

MESALAZINE (12198B)

mesalazine 1 g suppository, 28
12198B
Body System:
Manner of administration:Rectal
General Schedule
Restricted Benefit

Restriction

Indication: Mild to moderate ulcerative proctitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 28 # of repeats: 5 DPMQ: $81.95 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pentasa

MESALAZINE (12203G)

mesalazine 1 g modified release granules, 100 sachets
12203G
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: $105.07 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pentasa

MESALAZINE (12463Y)

mesalazine 1.6 g enteric tablet, 60
12463Y
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Ulcerative colitis
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: 4 DPMQ: $150.24 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Asacol

MESALAZINE (13247F)

mesalazine 1.2 g modified release tablet, 120
13247F
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Ulcerative colitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 1 Max qty units: 120 # of repeats: 5 DPMQ: $169.54 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
MESALZ

MESALAZINE (13355X)

mesalazine 1 g modified release granules, 100 sachets
13355X
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: $199.86 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Pentasa

MESALAZINE (13356Y)

mesalazine 1.2 g modified release tablet, 120
13356Y
Body System:
Manner of administration:Oral
General Schedule
Restricted Benefit

Restriction

Indication: Ulcerative colitis
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 2 Max qty units: 240 # of repeats: 5 DPMQ: $329.72 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
MESALZ