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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
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
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