Displaying 1 - 4 of 4
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 4701AV REFRESH OPTIVE GEL 1% | 0.9% EYE DR (ALL/COL) CARBOXYMETHYLCELLULOSE | GLYCERINE 10ML C 12.91 1%|0.9% 0 2022-04-01 2024-03-31 0
41 4701AV REFRESH OPTIVE GEL 1%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULO (C) 10ML C 12.912 1%|0.9% 0 2024-04-01 2026-03-31 0
40 4701K OPTIVE .05%C/0.9%G EYE DR (ALL/COL) CARBOXY/G 15ML C 13.59 0.05%|0.9% 0 2022-04-01 2024-03-31 0
41 4701K OPTIVE 0.5%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULOSE|GLYCERI (C) 15ML C 13.5916 0.5%|0.9% 0 2024-04-01 2026-03-31 0