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Contract Number Brand Code Brand Name Active Ingredient Trade Name Package Size Formulary Category Pkg Price Unit Price Unit Description Max. Reimbursable Quantity / Month Package Description Manufacturer Code Manufacturer Name Agent Code Agent Name Benefit Therapeutic Code Therapeutic Desc Drug Contract Start Date Drug Contract End Date Status Description Default Route Max Repeats Therapeutic Head Amend Date
40 4181G HERCEPTIN 600MG SC INJ (ROC/AHI) TRASTUZUMAB TRASTUZUMAB HERCEPTIN 5ML VIAL C 3,982.34 3,982.34 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 SC 0 ANTINEOPLASTICS
41 4181G HERCEPTIN 600MG SC INJ (ROC) TRASTUZUMAB (C) TRASTUZUMAB HERCEPTIN 5ML VIAL C 3982.34 3982.3447 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 SC 0 ANTINEOPLASTICS
42 4181G HERCEPTIN 600MG SC INJ (ROC) TRASTUZUMAB TRASTUZUMAB HERCEPTIN 5ML VIAL BQ 3,384.99 3,384.99 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2026-04-01 2028-03-31 SC 0 ANTINEOPLASTICS
40 4181J ACTEMRA 162MG/0.9ML INJ (ROC/AHI) TOCILIZUMAB TOCILIZUMAB ACTEMRA 4X0.9ML C 706.76 176.69 INJECTION 0 AMP ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181J ACTEMRA 162MG/0.9ML INJ (ROC) TOCILIZUMA (C) TOCILIZUMAB ACTEMRA 4X0.9ML C 1698.95 424.7381 AMP 0 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 9236 DISEASE MODIFYING ANTIRHEUMATIC AGENTS 2024-04-01 2026-03-31 IV 0 DISEASE MODIFYING ANTIRHEUMATIC AGENTS
42 4181J ACTEMRA 162MG/0.9ML INJ (ROC) TOCILIZUMA TOCILIZUMAB ACTEMRA 4X0.9ML BQ 1,698.95 424.74 AMPG 0 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 9236 DISEASE MODIFYING ANTIRHEUMATIC AGENTS 2026-04-01 2028-03-31 IV 0 DISEASE MODIFYING ANTIRHEUMATIC AGENTS
41 4181K PERJETA 420MG INJ (ROC) PERTUZUMAB (C) PERTUZUMAB PERJETA 14ML C 8644.27 8644.2703 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
42 4181K PERJETA 420MG INJ (ROC) PERTUZUMAB PERTUZUMAB PERJETA 14ML BQ 8,644.27 8,644.27 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2026-04-01 2028-03-31 IV 0 ANTINEOPLASTICS
41 4181N RITUXIMAB 10MG/ML INJ (RLS) (BQ) RITUXIMAB RITUXIMAB 10ML BQ 190.01 190.0108 VIAL 0 VIAL RLS RELIANCE LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
41 4181PB SIMULECT 20MG INJ (NVS) BAILIXIMAB (C) BASILIXIMAB SIMULECT 20MG VIAL C 4892.98 4892.9832 VIAL 0 VIAL NVS NOVARTIS CARIBE SA COL COLLINS LTD 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
42 4181PB SIMULECT 20MG INJ (NVS) BASILIXIMAB BASILIXIMAB SIMULECT 20MG VIAL C 4,892.98 4,892.98 VIAL 0 VIAL NVS NOVARTIS CARIBE SA COL AVENTA BARBADOS 1000 ANTINEOPLASTICS 2026-04-01 2028-03-31 IV 0 ANTINEOPLASTICS
40 4181S ACCENTRIX 10MG/ML INJ (NVS/COL) RANIBIZUMAB RANIBIZUMAB ACCENTRIX 1 DOSE C 788.31 788.31 INJECTION 0 VIAL NVS NOVARTIS CARIBE SA COL COLLINS LTD 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181S ACCENTRIX 10MG/ML INJ (NVS) RANIBIZUMAB (C) RANIBIZUMAB ACCENTRIX 1 DOSE C 788.31 788.314 VIAL 0 VIAL NVS NOVARTIS CARIBE SA COL COLLINS LTD 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
42 4181S ACCENTRIX 10MG/ML INJ (NVS) RANIBIZUMAB RANIBIZUMAB ACCENTRIX 1 DOSE C 788.31 788.31 VIAL 0 VIAL NVS NOVARTIS CARIBE SA COL AVENTA BARBADOS 1000 ANTINEOPLASTICS 2026-04-01 2028-03-31 IV 0 ANTINEOPLASTICS
40 4181T KADCYLA 100MG/ML INJ (ROC/AHI) ADO-TRASTUZUMAB EMTANSINE ADO-TRASTUZUMAB EMTANSINE KADCYLA 15ML C 5,844.40 5,844.40 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181T KADCYLA 100MG/ML INJ (ROC) ADO-TRASTUZUMAB EMTANSINE (C) ADO-TRASTUZUMAB EMTANSINE KADCYLA 15ML C 5844.4 5844.3966 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
42 4181T KADCYLA 100MG/ML INJ (ROC) ADO-TRASTUZUMAB EMTANSINE ADO-TRASTUZUMAB EMTANSINE KADCYLA 15ML C 5,552.18 5,552.18 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2026-04-01 2028-03-31 IV 0 ANTINEOPLASTICS
40 4181U KADCYLA 160MG/ML INJ (ROC/AHI) ADO-TRASTUZUMAB EMTANSINE ADO-TRASTUZUMAB EMTANSINE KADCYLA 20ML C 9,351.03 9,351.03 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181U KADCYLA 160MG/ML INJ (ROC) ADO-TRASTUZUMAB EMTANSINE (C) ADO-TRASTUZUMAB EMTANSINE KADCYLA 20ML C 9351.03 9351.0346 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
42 4181U KADCYLA 160MG/ML INJ (ROC) ADO-TRASTUZUMAB EMTANSINE ADO-TRASTUZUMAB EMTANSINE KADCYLA 20ML C 8,883.48 8,883.48 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2026-04-01 2028-03-31 IV 0 ANTINEOPLASTICS