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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
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