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Contract Number Brand Code Brand Name Active Ingredient Trade Name Package Size Formulary Category Pkg Price Unit Price Unit Description Max. Reimbursable Quantity / Month Package Description Manufacturer Code Manufacturer Name Agent Code Agent Name Benefit Therapeutic Code Therapeutic Desc Drug Contract Start Date Drug Contract End Date Status Description Default Route Max Repeats Therapeutic Head Amend Date
40 30612 RHOPHYLAC 300MCG INJ (CSL/AHI) ANTI-D IMMUNOG ANTI-D IMMUNOGLOBULIN RHOPHYLAC 2ML AMP BQ 108.73 108.73 INJECTION 0 AMP CSL CSL BEHRING AG AHI ARMSTRONG HEALTHCARE INC 8004 SERUMS 2022-04-01 2024-03-31 IV 0 SERUMS, TOXOIDS AND VACCINES
41 30612 RHOPHYLAC 300MCG INJ (CSL) ANTI-D IMMUNO ANTI-D IMMUNOGLOBULIN RHOPHYLAC 2ML AMP BQ 122.32 122.3246 AMP 2 AMP CSL CSL BEHRING AG AHI ARMSTRONG HEALTHCARE INC 8004 SERUMS 2024-04-01 2026-03-31 IV 0 SERUMS
40 3061B HYPERRHOD 300MCG INJ (GRB/COL) ANTI D IMMUNOG ANTI-D IMMUNOGLOBULIN HYPERRHOD 300MCG VL BQ 250.09 250.09 INJECTION 0 VIAL GRB GRIFOLS BIOLOGICALS INC COL COLLINS LTD 8004 SERUMS 2022-04-01 2024-03-31 IV 0 SERUMS, TOXOIDS AND VACCINES