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 51311 XALACOM 0.005% /0.5% EYE DR (PFI/STO) LATANOP 2.5ML C 28.68 0.005%|0.5% 0 2022-04-01 2024-03-31 0
40 51311 XALACOM 0.005% /0.5% EYE DR (PFI/STO) LATANOP 2.5ML C 37.89 0.005%|0.5% 0 2022-07-27 2024-03-31 Price Change 0
41 51311 XALACOM 0.005%|0.5% EYE DR (PFI) LATANOPROST|TIMOLOL (C) 2.5ML C 34.5771 0.005%|0.5% 1 2024-04-01 2026-03-31 Yes 6
40 51313 LOUTEN T 0.005% | 0.5% EYE DR (LPO/COL) LATANOP 2.5ML A 13.05 0.005%|0.5% 1 2022-04-01 2024-03-31 6
41 51313 LOUTEN T 0.005%|0.5% EYE DR (LPO) LATANO 2.5ML A 14.3528 0.005%|0.5% 1 2024-04-01 2026-03-31 Yes 6
40 51316 XALACOM 0.005% /0.5% EYE DR (PFI/SBI) LATANOP 2.5ML C 37.90 0.005%|0.5% 0 2022-04-01 2024-03-31 Price Change 0
41 51316 XALACOM 0.005%|0.5% EYE DR (PFI) LATANOPROST|TIMOLOL (C) 2.5ML C 34.5771 0.005%|0.5% 1 2024-04-01 2026-03-31 Yes 6