Displaying 1 - 6 of 6
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 A471S DALTEPARIN 2500IU INJ (GLN/AHI) 2500IU B 5.08 2500IU 0 2022-04-01 2022-09-30 0
40 A472AD DALTEPARIN 5000IU INJ (GLN/AHI) 5000IU B 7.88 5000IU 0 2022-04-01 2022-06-29 0
40 A472AD DALTEPARIN 5000IU INJ (GLN/AHI) 5000IU B 24.06 5000IU 0 2022-06-30 2024-03-31 Price Change 0
41 A472AD DALTEPARIN 5000IU INJ (GLN) (B) 5000IU B 24.0572 5000IU 10 2024-04-01 2026-03-31 6
42 A472AD DALTEPARIN 5000IU INJ (GLN) 5000IU BQ 24.06 5000IU 10 2026-04-01 No No 0
41 A472BM DALTEPARIN 5000IU INJ (LDP) (B) 0.4ML PFS B 22.6165 5000IU 10 2024-04-01 2026-03-31 6