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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 A0814 PNEUMOVAX 23 25MCG INJ (MSD/STO) PNEUMOCOCCAL PNEUMOCOCCAL PNEUMOVAX 23 10X0.5ML B 239.78 23.98 INJECTION 0 AMP MSD MERCK SHARP & DOHME (I.A.) CORP STO BRYDEN STOKES LTD 8012 VACCINES 2022-04-01 2024-03-31 IV 0 SERUMS, TOXOIDS AND VACCINES