Displaying 1 - 3 of 3
Contract Number Brand Code Brand Name Package Size Formulary Category Unit Price Strength Max. Reimbursable / Month Drug Contract Start Date Drug Contract End Date Restrict To Ophthalmologist Restrict To Pulmonologist Status Description Max Repeats
40 76712 ACTILYSE 50MG INJ (BOE/STO) ALTEPLASE 2X50MG BQ 2,408.97 50MG 0 2022-04-01 2024-03-31 0
41 76712 ACTILYSE 50MG INJ (BOE) ALTEPLASE (BQ) 2X50MG BQ 2653.6143 50MG 0 2024-04-01 2026-03-31 0
42 76712 ACTILYSE 50MG INJ (BOE) ALTEPLASE 2X50MG BQ 2,653.62 50MG 0 2026-04-01 No No 0