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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
42 B1523 XARELTO 15MG TAB (BSP) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 85.03 3.04 TAB 30 BLIS BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2026-04-01 2028-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
40 B1524 PRADAX 110MG TAB (BOE/STO) DABIGATRAN DABIGATRAN PRADAX 60'S BQ 177.51 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 B1524 PRADAX 110MG TAB (BOE) DABIGATRAN (BQ) DABIGATRAN PRADAX 60'S BQ 193.27 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 B1524 PRADAX 110MG TAB (BOE) DABIGATRAN DABIGATRAN PRADAX 60'S B 193.27 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 B1525 XARELTO 15MG TAB (BSP/COL) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 169.92 6.07 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1525 XARELTO 15MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 28'S C 169.92 6.0687 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 B1525 XARELTO 15MG TAB (BSP) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 77.39 2.76 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 B1526 ELIQUIS 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 B1526 ELIQUIS 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 B1526 ELIQUIS 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
40 B1527 XARELTO 15MG TAB (BSP/AHI) RIVAROXABAN RIVAROXABAN XARELTO 14'S C 84.97 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 B1527 XARELTO 15MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 14'S C 84.97 6.0696 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
40 B1528 XARELTO 15MG TAB (BSP/COL) RIVAROXABAN RIVAROXABAN XARELTO 14'S C 84.97 6.07 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1528 XARELTO 15MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 14'S C 84.97 6.0696 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 B152AC DEBIJOHN 110MG CAP (JLP) DABIGATRAN DABIGATRAN DEBIJOHN 10X10 B 51.38 0.51 CAP 60 BLIS JLP JOHN LEE PHARMACEUTICALS AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2026-04-01 2028-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
42 B152N APO-APIXABAN 5MG TAB (APO) APIXABAN APO-APIXABAN 60'S B 32.62 0.54 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 B152S PMS-RIVAROXABAN 15MG 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 B1531 PRADAX 150MG TAB (BOE/STO) DABIGATRAN DABIGATRAN PRADAX 60'S BQ 177.51 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 B1531 PRADAX 150MG TAB (BOE) DABIGATRAN (BQ) DABIGATRAN PRADAX 60'S BQ 193.27 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 B1531 PRADAX 150MG TAB (BOE) DABIGATRAN DABIGATRAN PRADAX 60'S B 193.27 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 2026-02-05