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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 33812 PURILON | GEL (CLP/IMS) ALGINATE | CARBOXYMETHYLCELLULOSE ALGINATE|CARBOXYMETHYLCELLULOSE PURILON 10X25G B 133.50 13.35 GEL 0 TUBE CLP COLOPLAST A/S IMS ISLANDS MEDICAL SUPPLIES INC 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2022-04-01 2024-03-31 TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS