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

Contract Number	42
Brand Code	A472AD
Brand Name	DALTEPARIN 5000IU INJ (GLN)
Active Ingredient	DALTEPARIN
Trade Name	DALTEPARIN
Package Size	5000IU
Formulary Category	BQ
Pkg Price	24.06
Unit Price	24.06
Strength	5000IU
Unit Description	PFS
Max. Reimbursable Quantity / Month	10
Package Description	BOX
Manufacturer Code	GLN
Manufacturer Name	GLAND
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	20120416
Therapeutic Desc	HEPARINS
Status Description
Default Route	IV
Max Repeats	0
Therapeutic Head	HEPARINS
Amend Date