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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 77116 AFM-T 1MG | 0.25MG EYE DR (ARP/AHI) FLUOROMETHOLONE | TETRAHYDROZOLINE FLUOROMETHOLONE|TETRAHYDROZOLINE AFM-T 5ML BQ 13.89 13.89 EYE DROP 0 BOTT ARP ARISTOPHARMA LTD AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 77116 AFM-T 1MG|0.25MG EYE DR (ARP) FLUOROMETHOLONE|TETRAHYDROZOLI FLUOROMETHOLONE|TETRAHYDROZOLINE AFM-T 5ML BQ 13.89 13.8906 BOTT 2 BOTT ARP ARISTOPHARMA LTD AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT UNCLASSIFIED
42 77117 METALONE PLUS 1MG|0.25MG EYE DR (INC) FLUOROMETHOLONE|TETRAH FLUOROMETHOLONE|TETRAHYDROZOLINE METALONE PLUS 5ML BQ 13.48 13.48 BOTT 2 BOTT INC INCEPTA PHARMACEUTICALS LIMITED AHI ARMSTRONG HEALTHCARE INC 520808 EENT CORTICOSTEROIDS 2026-04-01 OPHTHALMIC 0 EENT CORTICOSTEROIDS