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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
41 1232B ISOSORBIDE DINITRATE 5MG TAB (ROL) ISOSORBIDE DINITRATE ISOSORBIDE DINITRATE 100'S A 116.72 1.1672 TAB 120 BOX ROL ROXANE LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 241208 NITRATES AND NITRITES 2024-04-01 2026-03-31 ORAL 6 NITRATES AND NITRITES
40 1763L PROMETHAZINE 25MG/ML INJ (ROL/AHI) PROMETHAZINE PROMETHAZINE 25X1ML B 204.04 8.16 INJECTION 0 AMP ROL ROXANE LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 282492 ANXIOLYTICS, SEDATIVES AND HYPNOTICS MISCELLANEOUS 2022-04-01 2022-09-30 IV 0 CENTRAL NERVOUS SYSTEM DRUGS 2022-03-29
41 66615 FLECAINIDE 100MG TAB (ROL) (B) FLECAINIDE FLECAINIDE 60'S B 85.41 1.4235 TAB 90 BOX ROL ROXANE LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 240404 ANTIARRHYTHMIC AGENTS 2024-04-01 2026-03-31 ORAL 6 ANTIARRHYTHMIC AGENTS