Displaying 1 - 2 of 2
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 33811 INTRASITE GEL GEL (SMN/IMS) HYPROMELLOSE | PROPYLENE GLYCOL 10X25G B 13.35 | 0 2022-04-01 2024-03-31 0
41 33811 INTRASITE GEL GEL (SMN) HYPROMELLOSE|PROPYLENE GLYCOL 10X25G B 13.9994 0.1%|0.1% 0 2024-04-01 2026-03-31 0