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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 6732Z CONTRAPAQUE 300MG/ML INJ (UNI/AHI) IOHEXOL IOHEXOL CONTRAPAQUE 50ML BQ 42.70 42.70 INJECTION 0 VIAL UNI UNIQUE PHARMACEUTICAL LABORATORIES AHI ARMSTRONG HEALTHCARE INC 3668 ROENTGENOGRAPHY 2022-04-01 2024-03-31 IV 0 DIAGNOSTIC AGENTS
40 6734AQ CONTRAPAQUE 350MG/ML INJ (UNI/AHI) IOHEXOL IOHEXOL CONTRAPAQUE 50ML BQ 43.06 43.06 INJECTION 0 VIAL UNI UNIQUE PHARMACEUTICAL LABORATORIES AHI ARMSTRONG HEALTHCARE INC 3668 ROENTGENOGRAPHY 2022-04-01 2024-03-31 IV 0 DIAGNOSTIC AGENTS
40 6735E XULVARIO 350MG/ML INJ (UNI/AHI) IOHEXOL IOHEXOL XULVARIO 100ML BQ 55.62 55.62 INJECTION 0 BOTT UNI UNIQUE PHARMACEUTICAL LABORATORIES AHI ARMSTRONG HEALTHCARE INC 3668 ROENTGENOGRAPHY 2022-04-01 2024-03-31 IV 0 DIAGNOSTIC AGENTS