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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 53116 PENICILLAMINE 250MG CAP (SLS/AHI) PENICILLAMINE PENICILLAMINE 50'S A 150.32 3.01 CAPSULE 180 CAP SLS SAMARTH LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 6400 HEAVY METAL ANTAGONISTS 2022-04-01 2024-03-31 Oral 6 HEAVY METAL ANTAGONISTS
41 53117 PENICILLAMINE 250MG CAP (JOL) PENICILLAMINE PENICILLAMINE 50'S A 70.49 1.4097 CAP 180 BOX JOL JOLLY PHARMACEUTICALS PHA PHARMACY SALES CARIBBEAN 6400 HEAVY METAL ANTAGONISTS 2024-04-01 2026-03-31 ORAL 6 HEAVY METAL ANTAGONISTS
42 53117 PENICILLAMINE 250MG CAP (JOL) PENICILLAMINE PENICILLAMINE 50'S A 46.48 0.93 CAP 180 BLIS JOL JOLLY PHARMACEUTICALS PHA PHARMACY SALES CARIBBEAN 6400 HEAVY METAL ANTAGONISTS 2026-04-01 ORAL 6 HEAVY METAL ANTAGONISTS