Drugs available on Contract - [GLYCEROL 4G SUPPOS (MTP) GLYCERINE], []

Contract Number	42
Brand Code	4091S
Brand Name	GLYCEROL 4G SUPPOS (MTP) GLYCERINE
Active Ingredient	GLYCERINE
Trade Name	GLYCEROL
Package Size	12'S
Formulary Category	A
Pkg Price	9.46
Unit Price	0.79
Strength	4G
Unit Description	SUPP
Max. Reimbursable Quantity / Month	12
Package Description	BLIS
Manufacturer Code	MTP
Manufacturer Name	MARTINDALE PHARMACEUTICALS
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	0
Dentist Allowed	N
Therapeutic Code	5612
Therapeutic Desc	CATHARTICS AND LAXATIVES
Status Description
Default Route	RECTAL
Max Repeats	6
Therapeutic Head	CATHARTICS AND LAXATIVES
Amend Date