Drugs available on Contract - [SYSTANE 0.4%|0.3% EYE DR (ALC) POLYETHYLENE GLYCOL 400|PROPY (C)], []

Contract Number	41
Brand Code	4701AR
Brand Name	SYSTANE 0.4%\|0.3% EYE DR (ALC) POLYETHYLENE GLYCOL 400\|PROPY (C)
Active Ingredient	POLYETHYLENE GLYCOL 400\|PROPYLENE GLYCOL
Trade Name	SYSTANE
Package Size	15ML
Formulary Category	C
Pkg Price	20.25
Unit Price	20.2515
Strength	0.4%\|0.3%
Unit Description	BOTT
Max. Reimbursable Quantity / Month	1
Package Description	BOTT
Manufacturer Code	ALC
Manufacturer Name	ALCON LABORATORIES INC.
Agent Code	AHI
Agent Name	ARMSTRONG HEALTHCARE INC
Benefit
Benefit Cat Code
Drug Contract Start Date	2024-04-01
Drug Contract End Date	2026-03-31
Restrict To Ophthalmologist
Restrict To Pulmonologist
SIGCode
SIGFactor	0
Dentist Allowed	N
Therapeutic Code	5292
Therapeutic Desc	EENT DRUGS MISCELLANEOPUS
Status Description
Default Route	OPHTHALMIC
Max Repeats	6
Therapeutic Head	EENT DRUGS MISCELLANEOPUS
Amend Date