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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 6031Q REJUN 50MG TAB (SGL/AHI) CLOMIPHENE CLOMIPHENE REJUN 10'S C 4.21 0.42 TABLET 0 TAB SGL STERIL-GENE LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 681612 ESTROGEN AGONIST-ANTAGONIST 2022-04-01 2024-03-31 Oral 0 HORMONES AND SYNTHETIC SUBSTITUTES
41 B071R LEVETIRACETAM 1G TAB (SGL) (B) LEVETIRACETAM LEVETIRACETAM 10X10 B 71.87 0.7187 TAB 60 BOX SGL STERIL-GENE LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC B 281292 ANTICONVULSANTS MISCELLANEOUS 2024-04-01 2026-03-31 ORAL 6 ANTICONVULSANTS MISCELLANEOUS