Drugs available on Contract - [SIMPLOVIR 50MG/ML INJ (INC) ACYCLOVIR], []

Contract Number	42
Brand Code	5691S
Brand Name	SIMPLOVIR 50MG/ML INJ (INC) ACYCLOVIR
Active Ingredient	ACYCLOVIR
Trade Name	SIMPLOVIR
Package Size	500MG VIAL
Formulary Category	BQ
Pkg Price	11.93
Unit Price	11.93
Strength	50MG/ML
Unit Description	VIAL
Max. Reimbursable Quantity / Month	15
Package Description	VIAL
Manufacturer Code	INC
Manufacturer Name	INCEPTA PHARMACEUTICALS LIMITED
Agent Code	AHI
Agent Name	ARMSTRONG HEALTHCARE INC
Benefit
Benefit Cat Code	15
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	081832
Therapeutic Desc	NUCLEOSIDES AND NUCLEOTIDES
Status Description
Default Route	IV
Max Repeats	0
Therapeutic Head	NUCLEOSIDES AND NUCLEOTIDES
Amend Date