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 6432G LEUCOVORIN 50MG INJ (SLS/AHI) 10ML VIAL BQ 22.29 50MG 0 2022-04-01 2024-03-31 0
40 6432H LEUCOVORIN 50MG INJ (SLS/AHI) 5ML BQ 12.45 50MG 0 2022-04-01 2022-09-30 0
40 64358 LEUCOVORIN 15MG TAB (SLS/AHI) 20'S BQ 4.76 15MG 0 2022-04-01 2024-03-31 0
41 64358 LEUCOVORIN 15MG TAB (SLS) 20'S BQ 4.8943 15MG 0 2024-04-01 2026-03-31 0