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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 30914 TETAGAM 250IU INJ (CSL/AHI) TETANUS ANTITOXIN TETANUS ANTITOXIN TETAGAM 1ML AMP B 67.96 67.96 INJECTION 0 AMP CSL CSL BEHRING AG AHI ARMSTRONG HEALTHCARE INC 8004 SERUMS 2022-04-01 2024-03-31 IV 0 SERUMS, TOXOIDS AND VACCINES
41 30914 TETAGAM 250IU INJ (CSL) TETANUS ANTITOXI TETANUS ANTITOXIN TETAGAM 1ML AMP B 108.73 108.733 AMP 40 AMP CSL CSL BEHRING AG AHI ARMSTRONG HEALTHCARE INC 8012 VACCINES 2024-04-01 2026-03-31 IV 0 VACCINES