Drugs available on Contract - [ACETAZOLAMIDE 500MG INJ (MAT)], []

Contract Number	42
Brand Code	22827
Brand Name	ACETAZOLAMIDE 500MG INJ (MAT)
Active Ingredient	ACETAZOLAMIDE
Trade Name	ACETAZOLAMIDE
Package Size	500MG VIAL
Formulary Category	BQ
Pkg Price	189.39
Unit Price	189.39
Strength	500MG
Unit Description	VIAL
Max. Reimbursable Quantity / Month	10
Package Description	VIAL
Manufacturer Code	MAT
Manufacturer Name	MYLAN LABORATORIES
Agent Code	AHI
Agent Name	ARMSTRONG HEALTHCARE INC
Benefit
Benefit Cat Code
Drug Contract Start Date	2026-04-01
Drug Contract End Date	2028-03-31
Restrict To Ophthalmologist	No
Restrict To Pulmonologist	No
SIGCode
SIGFactor
Dentist Allowed	N
Therapeutic Code	402804
Therapeutic Desc	CARBONIC ANHYDRASE INHIBITORS
Status Description
Default Route	IV
Max Repeats	0
Therapeutic Head	CARBONIC ANHYDRASE INHIBITORS
Amend Date