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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 23132 MIOSTAT OCULAR 0.01% INJ (ALC/AHI) CARBACHOL CARBACHOL MIOSTAT OCULAR 1.5ML VIAL BQ 59.94 59.94 INJECTION 0 VIAL ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 524020 EENT MIOTICS 2022-04-01 2024-03-31 IV 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 23132 MIOSTAT OCULAR 0.01% INJ (ALC) CARBACHOL CARBACHOL MIOSTAT OCULAR 1.5ML VIAL BQ 55.18 55.182 VIAL 0 VIAL ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 524020 EENT MIOTICS 2024-04-01 2026-03-31 IV 0 EENT MIOTICS
42 23132 MIOSTAT OCULAR 0.01% INJ (ALC) CARBACHOL CARBACHOL MIOSTAT OCULAR 1.5ML VIAL BQ 52.95 52.95 VIAL 0 VIAL ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 524020 EENT MIOTICS 2026-04-01 IV 0 EENT MIOTICS
41 3541AB VITALUX PLUS TAB (ALC) MULTIVITAMINS (C) MULTIVITAMINS VITALUX PLUS 30'S C 28.62 0.9541 TAB 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 8828 MULTIVITAMIN PREPARATIONS 2024-04-01 2026-03-31 ORAL 0 MULTIVITAMIN PREPARATIONS
40 40418 B.S.S. SOLN (ALC/AHI) BALANCED SALT BALANCED SALT B.S.S. 15ML BQ 12.67 12.67 SOLUTION 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 40418 B.S.S. SOLN (ALC) BALANCED SALT (BQ) BALANCED SALT B.S.S. 15ML BQ 12.99 12.9936 BOTT 10 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT UNCLASSIFIED
42 40418 BSS SOLN (ALC) BALANCED SALT BALANCED SALT BSS 15ML BQ 14.11 14.11 BOTT 10 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 3658 OCULAR DISORDERS 2026-04-01 OPHTHALMIC 0 OCULAR DISORDERS
40 40439 B.S.S. PLUS SOLN (ALC/AHI) BALANCED SALT SOL BALANCED SALT B.S.S. PLUS 500ML BQ 32.48 32.48 SOLUTION 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
42 40439 B.S.S. PLUS SOLN (ALC) BALANCED SALT SO BALANCED SALT B.S.S. PLUS 500ML BQ 36.83 36.83 BOTT 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
40 4043A B.S.S (BAG) SOLN (ALC/AHI) BALANCED SALT BALANCED SALT B.S.S (BAG) 500ML BQ 29.33 29.33 SOLUTION 0 BAG ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4043A B.S.S (BAG) SOLN (ALC) BALANCED SALT (BQ) BALANCED SALT B.S.S (BAG) 500ML BQ 29.9 29.9016 BAG 10 BAG ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT UNCLASSIFIED
42 4043A BSS (BAG) SOLN (ALC) BALANCED SALT BALANCED SALT BSS (BAG) 500ML BQ 32.10 32.10 BAG 10 BAG ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
40 4701AP TEARS NATURALE FORTE EYE DR (ALC/AHI) DEXTRAN | GLYCERINE | HYPROMELLOSE DEXTRAN|GLYCERINE|HYPROMELLOSE TEARS NATURALE FORTE 15ML C 13.32 13.32 EYE DROP 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 4701AQ TEARS NATURALE II 0.1% | 0.3% EYE DR (ALC/AHI) DEXTRAN | HYPROMELLOSE DEXTRAN 70|HYPROMELLOSE TEARS NATURALE II 15ML C 12.67 12.67 EYE DROP 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701AQ TEARS NATURALE II 0.1%|0.3% EYE DR (ALC) DEXTRAN|HYPROMELLOS (C) DEXTRAN 70|HYPROMELLOSE TEARS NATURALE II 15ML C 17.89 17.8866 BOTT 1 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
42 4701AQ TEARS NATURALE II 0.1%|0.3% EYE DR (ALC) DEXTRAN 70|HYPROMEL DEXTRAN 70|HYPROMELLOSE TEARS NATURALE II 15ML C 16.31 16.31 BOTT 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
40 4701AR SYSTANE 0.4% | 0.3% EYE DR (ALC/AHI) POLYETHYLENE GLYCOL 400 | PROPYLENE GLYCOL POLYETHYLENE GLYCOL 400|PROPYLENE GLYCOL SYSTANE 15ML C 17.75 17.75 EYE DROP 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701AR SYSTANE 0.4%|0.3% EYE DR (ALC) POLYETHYLENE GLYCOL 400|PROPY (C) POLYETHYLENE GLYCOL 400|PROPYLENE GLYCOL SYSTANE 15ML C 20.25 20.2515 BOTT 1 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
42 4701AR SYSTANE 0.4%|0.3% EYE DR (ALC) POLYETHYLENE GLYCOL 400|PROPY POLYETHYLENE GLYCOL 400|PROPYLENE GLYCOL SYSTANE 15ML C 18.89 18.89 BOTT 1 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC A 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
40 4701AS SYSTANE GEL DROPS 0.4% | 0.3% EYE DR (ALC/AHI) POLYETHYLENE GLYCOL 400|PROPYLENE GLYCOL SYSTANE GEL DROPS 10ML C 16.26 16.26 EYE DROP 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS