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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 4701AZ DEXTRAN | HYPROMELLOSE 0.1% | 0.3% EYE DR (FSB/AT 15ML A 5.41 0.1%|0.3% 1 2022-04-01 2024-03-31 6