Displaying 1 - 7 of 7
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 4582A BERIATE 500IU INJ (CSL/AHI) FACTOR VIII 10ML VIAL BQ 244.65 500IU 0 2022-04-01 2024-03-31 0
41 4582A BERIATE 500IU INJ (CSL) FACTOR VIII (BQ) 10ML VIAL BQ 244.6492 500IU 12 2024-04-01 2026-03-31 0
40 4582P HEMOREL A 500IU INJ (RLS/AHI) FACTOR VIII 500IU VIAL BQ 330.28 500IU 0 2022-04-01 2024-03-31 0
41 4582P HEMOREL A 500IU INJ (RLS) FACTOR VI (BQ) 500IU VIAL BQ 305.8115 500IU 12 2024-04-01 2026-03-31 0
42 4582P HEMOREL A 500IU INJ (RLS) FACTOR VI 500IU VIAL BQ 309.48 500IU 12 2026-04-01 No No 0
41 4582Q XYNTHA 500IU INJ (PFI) FACTOR VIII (C) 500IU VIAL C 1065.882 500IU 12 2024-04-01 2026-03-31 0
42 4582T BERIATE 500IU INJ (CSL) FACTOR VIII 500IU VIAL BQ 244.65 500IU 12 2026-04-01 No No Add to Contract 0