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| 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 | A681GX | GENVOYA 150MG | 150MG | 200MG | 10MG TAB (GIL/COL) COBICSTAT | ELVITEGRAVIR | EM More ... | 30'S | BL | 10.73 | 150MG|150MG|200MG|10MG | 0 | 2022-04-01 | 2024-03-31 | 0 | ||||