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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 6432G LEUCOVORIN 50MG INJ (SLS/AHI) LEUCOVORIN LEUCOVORIN 10ML VIAL BQ 22.29 22.29 INJECTION 0 VIAL SLS SAMARTH LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 9212 ANTIDOTES 2022-04-01 2024-03-31 IV 0 UNCLASSIFIED THERAPEUTIC AGENTS
40 6432H LEUCOVORIN 50MG INJ (SLS/AHI) LEUCOVORIN LEUCOVORIN 5ML BQ 12.45 12.45 INJECTION 0 VIAL SLS SAMARTH LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 9212 ANTIDOTES 2022-04-01 2022-09-30 IV 0 UNCLASSIFIED THERAPEUTIC AGENTS 2022-03-29
40 64358 LEUCOVORIN 15MG TAB (SLS/AHI) LEUCOVORIN LEUCOVORIN 20'S BQ 95.28 4.76 TABLET 0 TAB SLS SAMARTH LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 9212 ANTIDOTES 2022-04-01 2024-03-31 Oral 0 UNCLASSIFIED THERAPEUTIC AGENTS
41 64358 LEUCOVORIN 15MG TAB (SLS) LEUCOVORIN LEUCOVORIN 20'S BQ 97.89 4.8943 TAB 0 BOX SLS SAMARTH LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 9212 ANTIDOTES 2024-04-01 2026-03-31 ORAL 0 ANTIDOTES