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

Contract Number	41
Brand Code	A472AD
Brand Name	DALTEPARIN 5000IU INJ (GLN) (B)
Active Ingredient	DALTEPARIN
Trade Name	DALTEPARIN
Package Size	5000IU
Formulary Category	B
Pkg Price	24.06
Unit Price	24.0572
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	2024-04-01
Drug Contract End Date	2026-03-31
Restrict To Ophthalmologist
Restrict To Pulmonologist
SIGCode
SIGFactor	0
Dentist Allowed	N
Therapeutic Code	20120416
Therapeutic Desc	HEPARINS
Status Description
Default Route	IV
Max Repeats	6
Therapeutic Head	HEPARINS
Amend Date