Drugs available on Contract - [DEX-LITOS PWDR (LAF) REHYDRATION SALTS], []

Contract Number	42
Brand Code	5062AK
Brand Name	DEX-LITOS PWDR (LAF) REHYDRATION SALTS
Active Ingredient	REHYDRATION SALTS
Trade Name	DEX-LITOS
Package Size	25'S
Formulary Category	C
Pkg Price	31.26
Unit Price	1.25
Strength
Unit Description	BOX
Max. Reimbursable Quantity / Month	10
Package Description	SACH
Manufacturer Code	LAF
Manufacturer Name	LABORATORIOS ALFA
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	4012
Therapeutic Desc	REPLACEMENT THERAPY
Status Description
Default Route	ORAL
Max Repeats	0
Therapeutic Head	REPLACEMENT THERAPY
Amend Date