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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 33811 INTRASITE GEL GEL (SMN/IMS) HYPROMELLOSE | PROPYLENE GLYCOL HYPROMELLOSE|PROPYLENE GLYCOL INTRASITE GEL 10X25G B 133.50 13.35 GEL 0 TUBE SMN SMITH & NEPHEW PHARMACEUTICALS IMS ISLANDS MEDICAL SUPPLIES INC 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2022-04-01 2024-03-31 TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS
41 33811 INTRASITE GEL GEL (SMN) HYPROMELLOSE|PROPYLENE GLYCOL HYPROMELLOSE|PROPYLENE GLYCOL INTRASITE GEL 10X25G B 139.99 13.9994 TUBE 0 BOX SMN SMITH & NEPHEW PHARMACEUTICALS IMS ISLANDS MEDICAL SUPPLIES INC 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2024-04-01 2026-03-31 TOPICAL 0 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS