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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
41 B1514 XARELTO 10MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 10'S C 60.54 6.0537 TAB 30 BOX BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
42 B1514 XARELTO 10MG TAB (BSP) RIVAROXABAN RIVAROXABAN XARELTO 10'S C 27.65 2.77 TAB 30 BLIS BSP BAYER SCHERING PHARMA AG. COL AVENTA BARBADOS 20120412 DIRECT THROMBIN INHIBITORS 2026-04-01 2028-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
40 B1516 ELIQUIS 2.5MG TAB (PFI/STO) APIXABAN APIXABAN ELIQUIS 60'S C 219.40 3.66 TABLET 0 TAB PFI PFIZER CORPORATION STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1516 ELIQUIS 2.5MG TAB (PFI) APIXABAN (B) APIXABAN ELIQUIS 60'S B 175.33 2.9222 TAB 60 BOX PFI PFIZER CORPORATION STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
42 B1516 ELIQUIS 2.5MG TAB (PFI) APIXABAN APIXABAN ELIQUIS 60'S B 175.33 2.92 TAB 60 BLIS PFI PFIZER CORPORATION STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2026-04-01 2028-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS 2026-03-05
41 B1517 XARELTO 2.5MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 28'S C 84.81 3.0289 TAB 60 BOX BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
42 B1517 XARELTO 2.5MG TAB (BSP) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 44.58 1.59 TAB 60 BLIS BSP BAYER SCHERING PHARMA AG. COL AVENTA BARBADOS 20120412 DIRECT THROMBIN INHIBITORS 2026-04-01 2028-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
40 B151A XARELTO 2.5MG TAB (BSP/AHI) RIVAROXABAN RIVAROXABAN XARELTO 56'S C 169.62 3.03 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B151A XARELTO 2.5MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 56'S C 169.62 3.029 TAB 60 BOX BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
40 B151C XARELTO 2.5MG TAB (BSP/AHI) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 84.81 3.03 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B151C XARELTO 2.5MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 28'S C 84.81 3.029 TAB 60 BOX BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
42 B151C XARELTO 2.5MG TAB (BSP) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 85.03 3.04 TAB 60 BLIS BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2026-04-01 2028-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
42 B151N APO-APIXABAN 2.5MG TAB (APO) APIXABAN APO-APIXABAN 60'S B 27.18 0.45 TAB 60 BOTT APO APOTEX INC. COL AVENTA BARBADOS 20120412 DIRECT THROMBIN INHIBITORS 2026-04-01 2028-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
42 B151Q APO-RIVAROXABAN 2.5MG TAB (APO) RIVAROXABAN APO-RIVAROXABAN 60'S B 81.55 1.36 TAB 60 BLIS APO APOTEX INC. COL AVENTA BARBADOS 20120412 DIRECT THROMBIN INHIBITORS 2026-04-01 2028-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
42 B151T PMS-RIVAROXABAN 10MG TAB (PMS) RIVAROXABAN PMS-RIVAROXABAN 100'S B 106.01 1.06 TAB 30 BOTT PMS PHARMASCIENCE COL AVENTA BARBADOS 20120412 DIRECT THROMBIN INHIBITORS 2026-04-01 2028-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
40 B1521 PRADAX 110MG TAB (BOE/STO) DABIGATRAN DABIGATRAN PRADAX 3X10 BQ 88.75 2.96 TABLET 0 TAB BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 6 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1521 PRADAX 110MG TAB (BOE) DABIGATRAN (BQ) DABIGATRAN PRADAX 3X10 BQ 96.64 3.2212 TAB 60 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
42 B1521 PRADAX 110MG TAB (BOE) DABIGATRAN DABIGATRAN PRADAX 3X10 B 96.64 3.22 TAB 60 BLIS BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2026-04-01 2028-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS 2026-01-28
40 B1523 XARELTO 15MG TAB (BSP/AHI) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 169.92 6.07 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1523 XARELTO 15MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 28'S C 169.92 6.0687 TAB 30 BOX BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS