Drugs available on Contract - [AMBISONE LIPOSOMAL 50MG INJ (GIL) A], []

Contract Number	42
Brand Code	0081AB
Brand Name	AMBISONE LIPOSOMAL 50MG INJ (GIL) A
Active Ingredient	AMPHOTERICIN B
Trade Name	AMBISONE LIPOSOMAL
Package Size	50MG VIAL
Formulary Category	BQ
Pkg Price	581.72
Unit Price	581.72
Strength	50MG
Unit Description	VIAL
Max. Reimbursable Quantity / Month	21
Package Description	VIAL
Manufacturer Code	GIL
Manufacturer Name	GILEAD
Agent Code	COL
Agent Name	AVENTA BARBADOS
Benefit
Benefit Cat Code	15
Drug Contract Start Date	2026-04-01
Drug Contract End Date
Restrict To Ophthalmologist	No
Restrict To Pulmonologist	No
SIGCode
SIGFactor	0
Dentist Allowed	N
Therapeutic Code	081428
Therapeutic Desc	POLYENES
Status Description
Default Route	IV
Max Repeats	0
Therapeutic Head	POLYENES
Amend Date