Drugs available on Contract - [SYSTANE BALANCE 0.6% EYE DR (ALC) P], []

Contract Number	42
Brand Code	4701AU
Brand Name	SYSTANE BALANCE 0.6% EYE DR (ALC) P
Active Ingredient	PROPYLENE GLYCOL
Trade Name	SYSTANE BALANCE
Package Size	10ML
Formulary Category	C
Pkg Price	20.63
Unit Price	20.63
Strength	0.6%
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	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	5292
Therapeutic Desc	EENT DRUGS MISCELLANEOPUS
Status Description
Default Route	OPHTHALMIC
Max Repeats	0
Therapeutic Head	EENT DRUGS MISCELLANEOPUS
Amend Date