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 40919 GLYCEROL ADULT 4G SUPPOS (MTP/COL) GLYCERINE 12'S A 0.39 4G 12 2022-06-02 2024-03-31 Add to Contract as Cat A 6
40 4091R GLYCERINE ADULT 2G SUPPOS (FLE/AHI) GLYCERINE 12'S A 0.21 2G 12 2022-04-01 2024-03-31 6
40 4092H GLYCERINE PAED 1G SUPPOS (FLE/AHI) GLYCERINE 12'S A 0.24 1G 12 2022-04-01 2024-03-31 0