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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
42 3091J TETAGAM P 250IU/ML PREFIL SYRN (CSL) IMMUNOGLOBULIN HUMAN TETANUS IMMUNOGLOBULIN HUMAN TETAGAM P 4X1ML PFS B 108.73 108.73 PFS 0 PFS CSL CSL BEHRING AG AHI ARMSTRONG HEALTHCARE INC 8004 SERUMS 2026-04-01 Add to Contract IM 0 SERUMS 2025-11-10