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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 5511AE SURE COMFORT 31GX5/16'' (ALM/PHA) INSULIN S INSULIN SYRINGE SURE COMFORT 31GX5|16'' 100'S A $22.83 $0.23 10 EACH ALM ALLISON MEDICAL PHA PHARMACY SALES CARIBBEAN B 682008 INSULINS 2022-04-01 2024-03-31 IV 6 HORMONES AND SYNTHETIC SUBSTITUTES