Drugs available on Contract - [JAYDESS 13.5MG IUD (BSP/AHI) LEVONORGESTREL], []

Contract Number	40
Brand Code	76125
Brand Name	JAYDESS 13.5MG IUD (BSP/AHI) LEVONORGESTREL
Active Ingredient	LEVONORGESTREL
Trade Name	JAYDESS
Package Size	1'S
Formulary Category	C
Pkg Price	258.24
Unit Price	258.24
Strength	13.5MG
Unit Description	INTRAUTERINE
Max. Reimbursable Quantity / Month	0
Package Description	EACH
Manufacturer Code	BSP
Manufacturer Name	BAYER SCHERING PHARMA AG.
Agent Code	AHI
Agent Name	ARMSTRONG HEALTHCARE INC
Benefit
Benefit Cat Code
Drug Contract Start Date	2022-04-01
Drug Contract End Date	2024-03-31
Restrict To Ophthalmologist
Restrict To Pulmonologist
SIGCode
SIGFactor	0
Dentist Allowed	No
Therapeutic Code	6812
Therapeutic Desc	CONTRACEPTIVES
Status Description
Default Route	VAGINAL
Max Repeats	0
Therapeutic Head	HORMONES AND SYNTHETIC SUBSTITUTES
Amend Date