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 B4213 JARDIANCE 10MG TAB (BOE/STO) EMPAGLIFLOZIN 30'S A 2.24 10MG 60 2022-04-01 2024-03-31 6
41 B4213 JARDIANCE 10MG TAB (BOE) EMPAGLIFLOZIN 30'S A 2.2417 10MG 60 2024-04-01 2026-03-31 6
40 B4214 JARDIANCE 25MG TAB (BOE/STO) EMPAGLIFLOZIN 30'S A 2.24 25MG 30 2022-04-01 2024-03-31 6
41 B4214 JARDIANCE 25MG TAB (BOE) EMPAGLIFLOZIN 30'S A 2.2417 25MG 30 2024-04-01 2026-03-31 6