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 A5319 GLAUCOPROST 0.004% EYE DR (LPO/COL) TRAVOPROS 3ML A 10.60 0.004% 1 2022-04-01 2024-03-31 6
41 A5319 GLAUCOPROST 0.004% EYE DR (LPO) TRAVOPRO (C) 3ML C 11.6616 0.004% 1 2024-04-01 2026-03-31 Yes 6
40 A531AZ TRAVATAN BAK 0.004% EYE DR (NVS/COL) TRAVOPROST 2.5ML A 10.87 0.004% 1 2022-04-01 2024-03-31 6
41 A531AZ TRAVATAN BAK 0.004% EYE DR (NVS) TRAVOPROST 2.5ML A 10.8733 0.004% 1 2024-04-01 2026-03-31 Yes 6