Displaying 1 - 8 of 8
| 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 | 4701AR | SYSTANE 0.4% | 0.3% EYE DR (ALC/AHI) POLYETHYLENE GLYCOL 400 | PROPYLENE GLYCOL | 15ML | C | 17.75 | 0.4%|0.3% | 0 | 2022-04-01 | 2024-03-31 | 0 | ||||
| 41 | 4701AR | SYSTANE 0.4%|0.3% EYE DR (ALC) POLYETHYLENE GLYCOL 400|PROPY (C) | 15ML | C | 20.2515 | 0.4%|0.3% | 1 | 2024-04-01 | 2026-03-31 | 6 | ||||
| 40 | 4701AS | SYSTANE GEL DROPS 0.4% | 0.3% EYE DR (ALC/AHI) | 10ML | C | 16.26 | 0.4%|0.3% | 0 | 2022-04-01 | 2024-03-31 | 0 | ||||
| 41 | 4701AS | SYSTANE GEL DROPS 0.4%|0.3% EYE DR (ALC) (C) | 10ML | C | 18.539 | 0.4%|0.3% | 1 | 2024-04-01 | 2026-03-31 | 6 | ||||
| 40 | 4701AT | SYSTANE ULTRA 0.4% | 0.3% EYE DR (ALC/AHI) POLYETHYLENE GLYCOL 400 | PROPYLENE G More ... | 10ML | C | 12.64 | 0.4%|0.3% | 0 | 2022-04-01 | 2024-03-31 | 0 | ||||
| 41 | 4701AT | SYSTANE ULTRA 0.4%|0.3% EYE DR (ALC) POLYETHYLENE GLYCOL 400 (C) | 10ML | C | 15.3313 | 0.4%|0.3% | 1 | 2024-04-01 | 2026-03-31 | 6 | ||||
| 40 | 4701AX | SYSTEAR 0.4% | 0.3% EYE DR (ARP/AHI) POLYETHYLENE GLYCOL 400 | PROPYLENE GLYCOL | 10ML | A | 7.34 | 0.4%|0.3% | 1 | 2022-04-01 | 2024-03-31 | 6 | ||||
| 41 | 4701AX | SYSTEAR 0.4%|0.3% EYE DR (ARP) POLYETHYLENE GLYCOL 400|PROPY | 10ML | A | 7.421 | 0.4%|0.3% | 1 | 2024-04-01 | 2026-03-31 | 6 | ||||