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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 3701AW TRUE METRIX (HOM/ALI) DIAGNOSTIC BLOOD GLUC DIAGNOSTIC BLOOD GLUCOSE TRUE METRIX 50'S A 30.04 30.04 GLUCOSE STRI 1 PACK HOM NIPRO DIAGNOSTICS ALI ALL HEALTH INC B 3626 DIABETES MELLITUS 2022-04-01 2024-03-31 6 DIAGNOSTIC AGENTS