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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 4701AQ TEARS NATURALE II 0.1% | 0.3% EYE DR (ALC/AHI) DEXTRAN | HYPROMELLOSE DEXTRAN 70|HYPROMELLOSE TEARS NATURALE II 15ML C 12.67 12.67 EYE DROP 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701AQ TEARS NATURALE II 0.1%|0.3% EYE DR (ALC) DEXTRAN|HYPROMELLOS (C) DEXTRAN 70|HYPROMELLOSE TEARS NATURALE II 15ML C 17.89 17.8866 BOTT 1 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
42 4701AQ TEARS NATURALE II 0.1%|0.3% EYE DR (ALC) DEXTRAN 70|HYPROMEL DEXTRAN 70|HYPROMELLOSE TEARS NATURALE II 15ML C 16.31 16.31 BOTT 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS