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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 B2231 HUMULIN-N 100U/ML INJ (LIL/STO) INSULIN ISOPH INSULIN ISOPHANE HUMULIN-N 10ML VIAL A 14.92 14.92 INJECTION 5 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2231 HUMULIN-N 100U/ML INJ (LIL) INSULIN ISOP INSULIN ISOPHANE HUMULIN-N 10ML VIAL A 20.36 20.3602 VIAL 5 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B2232 NOVOLIN-N 100U/ML INJ (NOV/COL) INSULIN ISOPH INSULIN ISOPHANE NOVOLIN-N 10ML VIAL A 11.96 11.96 INJECTION 5 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2232 NOVOLIN-N 100U/ML INJ (NOV) INSULIN ISOP INSULIN ISOPHANE NOVOLIN-N 10ML VIAL A 11.96 11.9606 VIAL 5 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B2234 HUMILIN-N CARTRIDGE 100U/ML INJ (LIL/STO) ISO INSULIN ISOPHANE HUMILIN-N CARTRIDGE 5X3ML C 59.42 11.88 INJECTION VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD 682008 INSULINS 2022-07-11 2024-03-31 Add to Contract as Cat C SC HORMONES AND SYNTHETIC SUBSTITUTES 2022-07-11
41 B2234 HUMULIN-N CARTRIDGE 100U/ML INJ (LIL) INSULIN ISOPHANE (C) INSULIN ISOPHANE HUMULIN-N CARTRIDGE 5X3ML C 56.05 11.2104 VIAL 5 BOX LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B2241 LEVEMIR PEN 100U/ML INJ (NOV/COL) DETEMIR DETEMIR LEVEMIR PEN 5X3ML A 129.39 25.88 INJECTION 1 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2241 LEVEMIR PEN 100U/ML INJ (NOV) DETEMIR INSULIN DETEMIR LEVEMIR PEN 5X3ML A 129.39 25.878 BOX 2 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B2244 LANTUS SOLOSTAR 100U/ML INJ (SFA/COL) GLARGIN GLARGINE LANTUS SOLOSTAR 3ML VIAL A 27.18 27.18 INJECTION 5 VIAL SFA SANOFI AVENTIS COL COLLINS LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2244 LANTUS SOLOSTAR 100U/ML INJ (SFA) INSULIN GLARGINE INSULIN GLARGINE LANTUS SOLOSTAR 3ML VIAL A 27.18 27.1832 VIAL 2 VIAL SFA SANOFI AVENTIS COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS 2024-04-01
40 B2246 LANTUS 100U/ML INJ (SFA/COL) GLARGINE GLARGINE LANTUS 10ML VIAL A 67.96 67.96 INJECTION 5 VIAL SFA SANOFI AVENTIS COL COLLINS LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2246 LANTUS 100U/ML INJ (SFA) INSULIN GLARGINE INSULIN GLARGINE LANTUS 10ML VIAL A 67.96 67.9581 VIAL 5 VIAL SFA SANOFI AVENTIS COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B2248 TOUJEO 450IU INJ (SFA/COL) GLARGINE GLARGINE TOUJEO 1.5ML VIAL C 68.09 68.09 INJECTION 0 VIAL SFA SANOFI AVENTIS COL COLLINS LTD 682008 INSULINS 2022-04-01 2024-03-31 SC 0 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2248 TOUJEO 300U/ML INJ (SFA) INSULIN GLARGINE (C) INSULIN GLARGINE TOUJEO 1.5ML VIAL C 68.09 68.094 VIAL 0 VIAL SFA SANOFI AVENTIS COL COLLINS LTD 682008 INSULINS 2024-04-01 2026-03-31 SC 0 INSULINS
40 B2251 HUMULIN 70% | 30% INJ (LIL/STO) INSULIN ISOPHANE | INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR HUMULIN 10ML VIAL A 14.92 14.92 INJECTION 5 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2251 HUMULIN 70%|30% INJ (LIL) INSULIN ISOPHANE|INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR HUMULIN 10ML VIAL A 21.23 21.23 VIAL 5 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2024-04-01 2024-10-04 SC 6 INSULINS 2024-08-23
40 B2252 NOVOLIN 70% | 30% INJ (NOV/COL) INSULIN ISOPHANE | INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR NOVOLIN 10ML VIAL A 11.96 11.96 INJECTION 5 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2252 NOVOLIN 70%|30% INJ (NOV) INSULIN ISOPHANE|INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR NOVOLIN 10ML VIAL A 11.96 11.9606 VIAL 5 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
41 B2255 NOVOMIX 70/30 PENFILLS 100U/ML INJ (NOV) ASPART INSULIN ASPART NOVOMIX 70/30 PENFILLS 5X3ML A 122.32 24.4649 VIAL 2 BOX NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B2256 NOVOMIX 70/30 FLEXPENS INJ (NOV/COL) ASPART ASPART NOVOMIX 70|30 FLEXPENS 5X3ML A 122.32 24.46 INJECTION 1 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES