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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 4211BE BETAZOLE 0.25% | 1% CR (LDP/AHI) BECLOMETHASONE | CLOTRIMAZOLE BECLOMETHASONE|CLOTRIMAZOLE BETAZOLE 10G A 3.18 3.18 CREAM 2 TUBE LDP LABDHI PHARMA AHI ARMSTRONG HEALTHCARE INC 8410 ANTI-INFECTIVES & ANTI-INFLAMMATORIES 2022-04-01 2024-03-31 TOPICAL 6 SKIN-MUCOUS MEMBRANE PREPARATIONS