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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 68911 E-Z-GAS II (EZM/COL) SOD BIC/CIT ACID/SIMET CITRIC ACID|SIMETHICONE|SODIUM BICARBONATE E-Z-GAS II 50X4G BQ 462.12 9.24 0 SACH EZM E-Z-EM INC. COL COLLINS LTD 3668 ROENTGENOGRAPHY 2022-04-01 2024-03-31 Oral 0 DIAGNOSTIC AGENTS
41 68911 E-Z-GAS II (EZM) SOD BIC/CIT ACID/SIME (BQ) CITRIC ACID|SIMETHICONE|SODIUM BICARBONATE E-Z-GAS II 50X4G BQ 508.33 10.1665 SACH 0 BOX EZM E-Z-EM INC. COL COLLINS LTD 3668 ROENTGENOGRAPHY 2024-04-01 2026-03-31 ORAL 0 ROENTGENOGRAPHY
42 68911 E-Z-GAS II (EZM) SOD BIC/CIT ACID/SIME CITRIC ACID|SIMETHICONE|SODIUM BICARBONATE E-Z-GAS II 50X4G BQ 532.79 10.66 SACH 0 BOX EZM E-Z-EM INC. COL AVENTA BARBADOS 3668 ROENTGENOGRAPHY 2026-04-01 ORAL 0 ROENTGENOGRAPHY