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 B4911 XOLAIR 150MG INJ (NVS/COL) OMALIZUMAB 150MG VIAL C 1,304.93 150MG 0 2022-04-01 2024-03-31 0
41 B4911 XOLAIR 150MG INJ (NVS) OMALIZUMAB (C) 150MG VIAL C 1304.9314 150MG 0 2024-04-01 2026-03-31 0
40 B4913 OMALIREL 150MG INJ (RLS/AHI) OMALIZUMAB 150MG VIAL C 844.86 150MG 0 2022-04-01 2024-03-31 0
41 B4913 OMALIREL 150MG INJ (RLS) OMALIZUMAB (C) 150MG VIAL C 844.8551 150MG 0 2024-04-01 2026-03-31 0