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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 0142B ERYTHROMYCIN 5% EYE OINT (AKI/AHI) ERYTHROMYCIN ERYTHROMYCIN 3.5G C 67.31 67.31 EYE OINTMENT 0 TUBE AKI AKORN INC. AHI ARMSTRONG HEALTHCARE INC 520404 EENT ANTIBACTERIALS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 03267 GENTAMICIN 0.3% EYE OINT (AKI/AHI) GENTAMICIN GENTAMICIN 3.5G C 156.87 156.87 EYE OINTMENT 0 TUBE AKI AKORN INC. AHI ARMSTRONG HEALTHCARE INC 520404 EENT ANTIBACTERIALS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 0813B EPHEDRINE HCL 50MG/ML INJ (AKI/AHI) EPHEDRINE HCL EPHEDRINE HCL 10X1ML B 2248.76 224.8761 INJ 30 VIAL AKI AKORN INC. AHI ARMSTRONG HEALTHCARE INC 121212 ALPHA & BETA ADRENERGIC AGONIST IV 6 AUTONOMIC DRUGS
40 2362G TROPICAMIDE 1% EYE DR (AKI/AHI) TROPICAMIDE TROPICAMIDE 15ML A 39.20 39.20 EYE DROP 1 BOTT AKI AKORN INC. AHI ARMSTRONG HEALTHCARE INC 5224 EENT MYDRIATICS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 2362J TROPICAMIDE 1% EYE DR (AKI/AHI) TROPICAMIDE TROPICAMIDE 15ML A 44.06 44.064 EYE DR 1 BOTT AKI AKORN INC. AHI ARMSTRONG HEALTHCARE INC 5224 EENT MYDRIATICS OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 30287 LIDPCAINE 2% SPRAY (AKI/AHI) LIDOCAINE LIDOCAINE LIDPCAINE 100ML B 38.49 38.4915 SPRAY 1 BOTT AKI AKORN INC. AHI ARMSTRONG HEALTHCARE INC 7200 LOCAL ANESTHETICS TOPICAL 0 LOCAL ANESTHETICS
41 5131P T BET PRES. FREE 0.5%|0.004% EYE DR (AKU/PSB) TIMOLOL|TRAVOPROST TIMOLOL|TRAVOPROST T BET PRES. FREE 3ML C 11.42 11.417 EYE DR 1 BOTT AKU AKUMS DRUGS AND PHARMACEUTICALS PSB PHARMACEUTICAL SOLUTIONS BARBA 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 62615 NATACIN 5% EYE DR (AKU/PSB) NATAMYCIN NATAMYCIN NATACIN 5ML BQ 5.52 5.5182 EYE DR 0 BOTT AKU AKUMS DRUGS AND PHARMACEUTICALS PSB PHARMACEUTICAL SOLUTIONS BARBA 520416 EENT ANTIFUNGALS OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 7421D LIDOCAINE|PRILOCAINE 2.5%|2.5% CR (AKI/AHI) LIDOCAINE|PRILOCAINE LIDOCAINE|PRILOCAINE 30G BQ 116.45 116.453 CR 1 TUBE AKI AKORN INC. AHI ARMSTRONG HEALTHCARE INC 7200 LOCAL ANESTHETICS TOPICAL 0 LOCAL ANESTHETICS
40 7912E ORPHENADRINE 30MG/ML INJ (AKI/AHI) ORPHENADRINE ORPHENADRINE 10X2ML C 690.07 69.01 INJECTION 0 AMP AKI AKORN INC. AHI ARMSTRONG HEALTHCARE INC 122092 SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 2022-04-01 2022-09-30 IV 0 AUTONOMIC DRUGS 2022-03-29