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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 A9619 DIFFERIN 0.1% GEL (DPT/STO) ADAPALENE ADAPALENE DIFFERIN 15G C 30.36 30.36 GEL 0 TUBE DPT DPT LABORATORIES INC/GALDERMA STO BRYDEN STOKES LTD 8428 KERATOLYTICS 2022-04-01 2024-03-31 TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS
40 A9621 DIFFERIN 0.1% GEL (DPT/STO) ADAPALENE ADAPALENE DIFFERIN 45G C 65.08 65.08 GEL 0 TUBE DPT DPT LABORATORIES INC/GALDERMA STO BRYDEN STOKES LTD 8428 KERATOLYTICS 2022-04-01 2024-03-31 TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS
40 A9624 DIFFERIN PUMP 0.3% GEL (DPT/STO) ADAPALENE ADAPALENE DIFFERIN PUMP 45G C 204.74 204.74 GEL 0 BOTT DPT DPT LABORATORIES INC/GALDERMA STO BRYDEN STOKES LTD 8428 KERATOLYTICS 2022-04-01 2024-03-31 TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS
40 A9631 DIFFERIN 0.1% CR (DPT/STO) ADAPALENE ADAPALENE DIFFERIN 45G C 65.86 65.86 CREAM 0 TUBE DPT DPT LABORATORIES INC/GALDERMA STO BRYDEN STOKES LTD 8428 KERATOLYTICS 2022-04-01 2024-03-31 TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS