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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 04861 EPAQ 0.75% VAG CR (PMA/AHI) METRONIDAZOLE METRONIDAZOLE EPAQ 40G A 27.46 27.46 VAGINAL CREA 1 TUBE PMA MORE PHARMA CORPORATION AHI ARMSTRONG HEALTHCARE INC 083092 ANTIPROTOZOALS, MISCELLANEOUS 2022-04-01 2024-03-31 VAGINAL 0 ANTI-INFECTIVE AGENTS
41 04862 EPAQ 0.75% VAG CR (PMA) METRONIDAZOLE METRONIDAZOLE EPAQ 40G A 16.99 16.9895 TUBE 1 BOX PMA MORE PHARMA CORPORATION AHI ARMSTRONG HEALTHCARE INC 083092 ANTIPROTOZOALS, MISCELLANEOUS 2024-04-01 2026-03-31 VAGINAL 0 ANTIPROTOZOALS, MISCELLANEOUS
40 04935 HIPREX 1G TAB (PMA/AHI) HEXAMINE MANDELATE HEXAMINE MANDELATE HIPREX 20'S C 53.82 2.69 TABLET 0 TAB PMA MORE PHARMA CORPORATION AHI ARMSTRONG HEALTHCARE INC 0836 URINARY ANTI-INFECTIVES 2022-04-01 2024-03-31 Oral 0 ANTI-INFECTIVE AGENTS
41 04935 HIPREX 1G TAB (PMA) HEXAMINE MANDELATE HEXAMINE MANDELATE HIPREX 20'S C 37.24 1.862 TAB 0 BOX PMA MORE PHARMA CORPORATION AHI ARMSTRONG HEALTHCARE INC 0836 URINARY ANTI-INFECTIVES 2024-04-01 2026-03-31 ORAL 0 URINARY ANTI-INFECTIVES
40 12121 MINITRAN 5MG PATCH (PMA/AHI) GLYCERYL TRINITR GLYCERYL TRINITRATE MINITRAN 30'S BQ 46.21 46.21 PATCH 0 PACK PMA MORE PHARMA CORPORATION AHI ARMSTRONG HEALTHCARE INC 241208 NITRATES AND NITRITES 2022-04-01 2024-03-31 TOPICAL 6 CARDIOVASCULAR DRUGS
41 12121 MINITRAN 5MG PATCH (PMA) GLYCERYL TRINIT (BQ) GLYCERYL TRINITRATE MINITRAN 30'S BQ 54.37 54.3665 PACK 6 BOX PMA MORE PHARMA CORPORATION AHI ARMSTRONG HEALTHCARE INC 241208 NITRATES AND NITRITES 2024-04-01 2026-03-31 TOPICAL 0 NITRATES AND NITRITES
41 1691B THIORIDAZINE 10MG TAB (MAT) THIORIDAZINE THIORIDAZINE 100'S A 221.9 2.219 TAB 360 BOTT MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 28160824 PHENOTHIAZINES 2024-04-01 2026-03-31 ORAL 6 PHENOTHIAZINES
42 1691B THIORIDAZINE 10MG TAB (MAT) THIORIDAZINE THIORIDAZINE 100'S A 221.90 2.22 TAB 360 BOTT MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 28160824 PHENOTHIAZINES 2026-04-01 ORAL 6 PHENOTHIAZINES
41 1692M THIORIDAZINE 25MG TAB (MAT) THIORIDAZINE THIORIDAZINE 100'S A 312.06 3.1206 TAB 360 BOTT MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 28160824 PHENOTHIAZINES 2024-04-01 2026-03-31 ORAL 6 PHENOTHIAZINES
42 1692M THIORIDAZINE 25MG TAB (MAT) THIORIDAZINE THIORIDAZINE 100'S A 312.06 3.12 TAB 360 BOTT MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 28160824 PHENOTHIAZINES 2026-04-01 ORAL 6 PHENOTHIAZINES
42 1693C THIORIDAZINE 50MG TAB (MAT) THIORIDAZINE THIORIDAZINE 1000'S A 364.42 0.36 TAB 300 BOTT MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 28160824 PHENOTHIAZINES 2026-04-01 ORAL 6 PHENOTHIAZINES
42 17016 TRIFLUOPERAZINE 1MG TAB (MAT) TRIFLUOPERAZINE TRIFLUOPERAZINE 1000'S A 153.01 0.15 TAB 252 BOTT MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 28160824 PHENOTHIAZINES 2026-04-01 ORAL 6 PHENOTHIAZINES
40 22827 ACETAZOLAMIDE 500MG INJ (MAT/AHI) ACETAZOLAMIDE ACETAZOLAMIDE 500MG VIAL BQ 182.67 182.67 INJECTION 0 VIAL MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 402804 CARBONIC ANHYDRASE INHIBITORS 2022-04-01 2024-03-31 IV 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE
41 22827 ACETAZOLAMIDE 500MG INJ (MAT) ACETAZOLAMIDE ACETAZOLAMIDE 500MG VIAL BQ 182.89 182.8888 VIAL 10 VIAL MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 402804 CARBONIC ANHYDRASE INHIBITORS 2024-04-01 2026-03-31 IV 6 CARBONIC ANHYDRASE INHIBITORS
42 22827 ACETAZOLAMIDE 500MG INJ (MAT) ACETAZOLAMIDE ACETAZOLAMIDE 500MG VIAL BQ 189.39 189.39 VIAL 10 VIAL MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 402804 CARBONIC ANHYDRASE INHIBITORS 2026-04-01 IV 0 CARBONIC ANHYDRASE INHIBITORS
42 2592AM FAMOTIDINE 10MG/ML INJ (MAT) FAMOTIDINE FAMOTIDINE 25X2 ML BQ 129.80 5.19 AMPG 0 AMP MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 562812 HISTAMINE RECEPTOR ANTAGONIST 2026-04-01 IV 0 HISTAMINE RECEPTOR ANTAGONIST
42 2593DU SUCRALFATE 1G TAB (MAT) SUCRALFATE SUCRALFATE 100'S A 83.81 0.84 TAB 120 BOTT MAT MYLAN LABORATORIES AHI ARMSTRONG HEALTHCARE INC 562832 GI PROTECTANTS 2026-04-01 ORAL 6 GI PROTECTANTS
40 66613 TAMBOCOR 100MG TAB (PMA/AHI) FLECAINIDE FLECAINIDE TAMBOCOR 25'S C 25.82 1.03 TABLET 0 TAB PMA MORE PHARMA CORPORATION AHI ARMSTRONG HEALTHCARE INC 240404 ANTIARRHYTHMIC AGENTS 2022-04-01 2024-03-31 Oral 0 CARDIOVASCULAR DRUGS
40 7911R NORGESIC 35MG | 500MG TAB (PMA/AHI) ORPHENADRINE | PARACETAMOL ORPHENADRINE|PARACETAMOL NORGESIC 10'S C 7.07 0.71 TABLET 0 TAB PMA MORE PHARMA CORPORATION AHI ARMSTRONG HEALTHCARE INC 122092 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 2022-04-01 2024-03-31 Oral 0 AUTONOMIC DRUGS
41 7911R NORGESIC 35MG|500MG TAB (PMA) ORPHENADRINE|PARACETAMOL (C) ORPHENADRINE|PARACETAMOL NORGESIC 10'S C 8.15 0.8155 TAB 0 BOX PMA MORE PHARMA CORPORATION AHI ARMSTRONG HEALTHCARE INC 122092 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 2024-04-01 2026-03-31 ORAL 0 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS