Drugs available on Contract - [DALTEPARIN 5000IU INJ (GLN/AHI) ], []

Contract Number	40
Brand Code	A472AD
Brand Name	DALTEPARIN 5000IU INJ (GLN/AHI)
Active Ingredient	DALTEPARIN
Trade Name	DALTEPARIN
Package Size	5000IU
Formulary Category	B
Pkg Price	24.06
Unit Price	24.06
Strength	5000IU
Unit Description	INJECTION
Max. Reimbursable Quantity / Month	0
Package Description	PFS
Manufacturer Code	GLN
Manufacturer Name	GLAND
Agent Code	AHI
Agent Name	ARMSTRONG HEALTHCARE INC
Benefit
Benefit Cat Code
Drug Contract Start Date	2022-06-30
Drug Contract End Date	2024-03-31
Restrict To Ophthalmologist
Restrict To Pulmonologist
SIGCode
SIGFactor	0
Dentist Allowed	No
Therapeutic Code	20120416
Therapeutic Desc	HEPARINS
Status Description	Price Change
Default Route	IV
Max Repeats	0
Therapeutic Head	BLOOD FORMATION, COAGULATION AND THROMBOSIS
Amend Date	2022-06-30