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 A661D RELPAX 40MG TAB (PFI/STO) ELETRIPTAN HBR 2'S C 11.99 40MG 0 2022-04-01 2024-03-31 0
41 A661D RELPAX 40MG TAB (PFI) ELETRIPTAN HBR (C) 2'S C 12.0966 40MG 0 2024-04-01 2026-03-31 0
40 A661R RELPAX 40MG TAB (PFI/SBI) ELETRIPTAN HBR 2'S C 11.99 40MG 0 2022-04-01 2024-03-31 0
41 A661R RELPAX 40MG TAB (PFI) ELETRIPTAN HBR (C) 2'S C 12.0966 40MG 0 2024-04-01 2026-03-31 0