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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 22826 ACETAZOLAMIDE 500MG INJ (XGE/AHI) ACETAZOLAMIDE ACETAZOLAMIDE 1DOSE SYRN BQ 165.44 165.44 INJECTION 0 PFS XGE X-GEN PHARMACEUTICALS INC AHI ARMSTRONG HEALTHCARE INC 402804 CARBONIC ANHYDRASE INHIBITORS 2022-04-01 2022-09-30 IV 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE 2022-03-29