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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 A471S DALTEPARIN 2500IU INJ (GLN/AHI) DALTEPARIN DALTEPARIN 2500IU B 5.08 5.08 INJECTION 0 PFS GLN GLAND AHI ARMSTRONG HEALTHCARE INC 20120416 HEPARINS 2022-04-01 2022-09-30 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS 2022-03-29
40 A472AD DALTEPARIN 5000IU INJ (GLN/AHI) DALTEPARIN DALTEPARIN 5000IU B 7.88 7.88 INJECTION 0 PFS GLN GLAND AHI ARMSTRONG HEALTHCARE INC 20120416 HEPARINS 2022-04-01 2022-06-29 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS 2022-03-29
40 A472AD DALTEPARIN 5000IU INJ (GLN/AHI) DALTEPARIN DALTEPARIN 5000IU B 24.06 24.06 INJECTION 0 PFS GLN GLAND AHI ARMSTRONG HEALTHCARE INC 20120416 HEPARINS 2022-06-30 2024-03-31 Price Change IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS 2022-06-30
41 A472AD DALTEPARIN 5000IU INJ (GLN) (B) DALTEPARIN DALTEPARIN 5000IU B 24.06 24.0572 PFS 10 BOX GLN GLAND AHI ARMSTRONG HEALTHCARE INC 20120416 HEPARINS 2024-04-01 2026-03-31 IV 6 HEPARINS
41 A472BM DALTEPARIN 5000IU INJ (LDP) (B) DALTEPARIN DALTEPARIN 0.4ML PFS B 22.62 22.6165 PFS 10 PFS LDP LABDHI PHARMA AHI ARMSTRONG HEALTHCARE INC 20120416 HEPARINS 2024-04-01 2026-03-31 SC 6 HEPARINS