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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 4701T ACRYLARM 0.2% GEL (LPO/COL) POLYACRYLIC ACID POLYACRYLIC ACID ACRYLARM 10G B 11.15 11.15 GEL 1 TUBE LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701T ACRYLARM 0.2% GEL (LPO) POLYACRYLIC ACID (B) POLYACRYLIC ACID ACRYLARM 10G B 12.26 12.2596 TUBE 1 BOX LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
42 4701T ACRYLARM 0.2% GEL (LPO) POLYACRYLIC ACID POLYACRYLIC ACID ACRYLARM 10G B 20.39 20.39 TUBE 1 BOX LPO LABORATORIOS POEN S.A. COL AVENTA BARBADOS 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS