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 3921CM DIPYRIDAMOLE 50MG TAB (LDP/AHI) 100'S BQ 0.50 50MG 120 2022-04-01 2024-03-31 Add to Contract as Cat B 6
40 3921CQ DIPYRIDAMOLE 25MG TAB (LDP/AHI) 100'S BQ 0.50 25MG 120 2022-04-01 2024-03-31 Add to Contract as Cat B 6
40 3921CS DIPYRIDAMOLE 75MG TAB (LDP/AHI) 100'S BQ 0.50 75MG 120 2022-04-01 2024-03-31 Add to Contract as Cat B 6