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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 5062AB REHYDRATION SALTS (CIP/AHI) REHYDRATION SALTS REHYDRATION SALTS 30'S A 17.91 0.60 10 SACH CIP CIPLA LTD AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2022-04-01 2024-03-31 Oral 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE
40 5062AD REHYDRATION SALTS PWDR (HEA/RXP) REHYDRATION SALTS REHYDRATION SALTS 30'S A 18.62 0.62 POWDER 10 SACH HEA HEALTH 2000 INC RXP RX PRO INC 4012 REPLACEMENT THERAPY 2022-04-01 2024-03-31 Oral 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE
41 5062AF PROLYTE ORS PWDR (CIP) REHYDRATION SALTS REHYDRATION SALTS PROLYTE ORS 40'S A 23.92 0.598 BOX 10 SACH CIP CIPLA LTD AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
42 5062AF PROLYTE ORS PWDR (CIP) REHYDRATION SALTS REHYDRATION SALTS PROLYTE ORS 40'S A 23.92 0.60 BOX 10 SACH CIP CIPLA LTD AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2026-04-01 ORAL 0 REPLACEMENT THERAPY
41 5062AK DEX-LITOS PWDR (LAF) REHYDRATION SALTS (C) REHYDRATION SALTS DEX-LITOS 25'S C 31.26 1.2504 BOX 0 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
42 5062AK DEX-LITOS PWDR (LAF) REHYDRATION SALTS REHYDRATION SALTS DEX-LITOS 25'S C 31.26 1.25 BOX 10 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2026-04-01 ORAL 0 REPLACEMENT THERAPY
41 5062AL DEX-LITOS PWDR (LAF) REHYDRATION SALTS (C) REHYDRATION SALTS DEX-LITOS 50'S C 63.88 1.2776 BOX 0 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
41 5062AM DEX-LITOS PWDR (LAF) REHYDRATION SALTS (C) REHYDRATION SALTS DEX-LITOS 25 SACH C 31.26 1.2504 BOX 0 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
41 5062AN DEX-LITOS PWDR (LAF) REHYDRATION SALTS (C) REHYDRATION SALTS DEX-LITOS 50 SACH C 63.88 1.2776 BOX 0 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
42 5062AN DEX-LITOS PWDR (LAF) REHYDRATION SALTS REHYDRATION SALTS DEX-LITOS 50 SACH C 63.88 1.28 BOX 10 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2026-04-01 ORAL 0 REPLACEMENT THERAPY
41 5062AP REHYDRATION SALTS ORANGE PWDR (MPI) REHYDRATION SALTS REHYDRATION SALTS ORANGE 100'S A 32.57 0.3257 BOX 10 SACH MPI MEPRO PHARMACEUTICALS INTERNATIONAL LTD AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY