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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 50512 HYDROGEN PEROXIDE 6% (FED/ATB) HYDROGEN PEROXIDE HYDROGEN PEROXIDE 150ML B 2.58 0.02 SOLUTION 0 ML FED FEDERATED PHARMACEUTICAL CO. LT ATB ANSA TRADING BARBADOS LTD 5228 MOUTH WASHES AND GARGLES 2022-05-11 2024-03-31 Change Local Agent TOPICAL 0 EYE, EAR, NOSE AND THROAT PREPARATIONS 2022-05-11
40 50514 HYDROGEN PEROXIDE 6% (FED/RXP) HYDROGEN PEROXIDE HYDROGEN PEROXIDE 150ML B 2.58 0.02 SOLUTION 0 ML FED FEDERATED PHARMACEUTICAL CO. LT RXP RX PRO INC 5228 MOUTH WASHES AND GARGLES 2022-04-01 2022-05-11 Delete from contract TOPICAL 0 EYE, EAR, NOSE AND THROAT PREPARATIONS 2022-05-11
40 5051H HYDROGEN PEROXIDE 6% (THR/SBI) HYDROGEN PEROXIDE HYDROGEN PEROXIDE 200ML B 1.85 0.01 SOLUTION 0 ML THR THORNTON & ROSS LTD SBI MASSY DISTRIBUTION (BDOS) LTD 5228 MOUTH WASHES AND GARGLES 2022-04-01 2024-03-31 TOPICAL 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 5051M HYDROGEN PEROXIDE 6% SOLN (LDP) (B) HYDROGEN PEROXIDE HYDROGEN 250ML B 4.87 0.0195 ML 0 BOTT LDP LABDHI PHARMA AHI ARMSTRONG HEALTHCARE INC 9244 IMMUNOSUPPRESSIVE AGENTS 2024-04-01 2026-03-31 TOPICAL 0 IMMUNOSUPPRESSIVE AGENTS
42 5051M HYDROGEN PEROXIDE 6% SOLN (LDP) HYDROGEN PEROXIDE HYDROGEN 250ML B 5.46 0.02 ML 0 BOTT LDP LABDHI PHARMA AHI ARMSTRONG HEALTHCARE INC 9244 IMMUNOSUPPRESSIVE AGENTS 2026-04-01 2028-03-31 TOPICAL 0 IMMUNOSUPPRESSIVE AGENTS
40 5062AB REHYDRATION SALTS (CIP/AHI) REHYDRATION SALTS REHYDRATION SALTS 30'S A 17.91 0.60 10 SACH CIP CIPLA LTD AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2022-04-01 2024-03-31 Oral 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE
40 5062AD REHYDRATION SALTS PWDR (HEA/RXP) REHYDRATION SALTS REHYDRATION SALTS 30'S A 18.62 0.62 POWDER 10 SACH HEA HEALTH 2000 INC RXP RX PRO INC 4012 REPLACEMENT THERAPY 2022-04-01 2024-03-31 Oral 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE
41 5062AF PROLYTE ORS PWDR (CIP) REHYDRATION SALTS REHYDRATION SALTS PROLYTE ORS 40'S A 23.92 0.598 BOX 10 SACH CIP CIPLA LTD AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
42 5062AF PROLYTE ORS PWDR (CIP) REHYDRATION SALTS REHYDRATION SALTS PROLYTE ORS 40'S A 23.92 0.60 BOX 10 SACH CIP CIPLA LTD AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2026-04-01 2028-03-31 ORAL 0 REPLACEMENT THERAPY
40 5062AJ REHYDRATION SALTS (HEA/ATB) GLUCOSE|POTASSIUM CHLORIDE|SODIUM CHLORIDE|SODIUM CITRATE REHYDRATION SALTS 30'S A 18.62 0.6207 SACHET HEA HEALTH 2000 INC ATB ANSA TRADING BARBADOS LTD 4012 REPLACEMENT THERAPY 2022-12-07 2024-03-31 Change Local Agent ORAL 0 REPLACEMENT THERAPY 2022-11-25
41 5062AK DEX-LITOS PWDR (LAF) REHYDRATION SALTS (C) REHYDRATION SALTS DEX-LITOS 25'S C 31.26 1.2504 BOX 0 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
42 5062AK DEX-LITOS PWDR (LAF) REHYDRATION SALTS REHYDRATION SALTS DEX-LITOS 25'S C 31.26 1.25 BOX 10 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2026-04-01 2028-03-31 ORAL 0 REPLACEMENT THERAPY
41 5062AL DEX-LITOS PWDR (LAF) REHYDRATION SALTS (C) REHYDRATION SALTS DEX-LITOS 50'S C 63.88 1.2776 BOX 0 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
41 5062AM DEX-LITOS PWDR (LAF) REHYDRATION SALTS (C) REHYDRATION SALTS DEX-LITOS 25 SACH C 31.26 1.2504 BOX 0 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
41 5062AN DEX-LITOS PWDR (LAF) REHYDRATION SALTS (C) REHYDRATION SALTS DEX-LITOS 50 SACH C 63.88 1.2776 BOX 0 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
42 5062AN DEX-LITOS PWDR (LAF) REHYDRATION SALTS REHYDRATION SALTS DEX-LITOS 50 SACH C 63.88 1.28 BOX 10 SACH LAF LABORATORIOS ALFA AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2026-04-01 2028-03-31 ORAL 0 REPLACEMENT THERAPY
41 5062AP REHYDRATION SALTS ORANGE PWDR (MPI) REHYDRATION SALTS REHYDRATION SALTS ORANGE 100'S A 32.57 0.3257 BOX 10 SACH MPI MEPRO PHARMACEUTICALS INTERNATIONAL LTD AHI ARMSTRONG HEALTHCARE INC 4012 REPLACEMENT THERAPY 2024-04-01 2026-03-31 ORAL 0 REPLACEMENT THERAPY
40 50831 NEBIDO 250MG/ML INJ (BSP/COL) TESTOSTERONE TESTOSTERONE NEBIDO 4ML VIAL BQ 108.73 108.73 INJECTION 0 VIAL BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 6808 ANDROGENS 2022-04-01 2024-03-31 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 50833 NEBIDO 250MG/ML INJ (BSP/AHI) TESTOSTERONE TESTOSTERONE NEBIDO 4ML VIAL BQ 108.73 108.73 INJECTION 0 VIAL BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 6808 ANDROGENS 2022-04-01 2024-03-31 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
42 50837 PRIMOTESTON 250MG/ML INJ (BSP) TESTOSTER TESTOSTERONE PRIMOTESTON 250MG AMP BQ 33.14 33.14 AMPG 4 AMP BSP BAYER SCHERING PHARMA AG. COL AVENTA BARBADOS 6808 ANDROGENS 2026-04-01 2028-03-31 IV 0 ANDROGENS