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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 06417 ACCORD MITOMYCIN 5MG INJ (INP/AAL) MITOMYCIN MITOMYCIN ACCORD MITOMYCIN 5MG VIAL BQ 203.06 203.06 INJECTION 0 VIAL INP INTAS PHARMACEUTICALS LTD AAL A. A. LAQUIS LTD 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS