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| 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 | 0232E | SYMBICORT RAPIHALER 160MCG | 4.5MCG INHR (AZN/COL) BUDESONIDE | FORMOTEROL (120 More ... | 120 DOSES | A | 37.68 | 160MCG|4.5MCG | 1 | 2022-04-01 | 2024-03-31 | 6 | ||||
| 41 | 0232E | SYMBICORT RAPIHALER 160MCG|4.5MCG INHR (AZN) BUDESONIDE|FORM | 120 DOSES | A | 37.676 | 160MCG|4.5MCG | 1 | 2024-04-01 | 2026-03-31 | 6 | ||||