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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 B1533 XARELTO 20MG 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 B1533 XARELTO 20MG 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
42 B1533 XARELTO 20MG 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 B1534 XARELTO 20MG 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 B1534 XARELTO 20MG 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 B1534 XARELTO 20MG 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 B1535 XARELTO 20MG 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 B1535 XARELTO 20MG 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 B1536 XARELTO 20MG 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 B1536 XARELTO 20MG 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 B153L PMS-RIVAROXABAN 20MG 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
42 B153R DEBIJOHN 150MG CAP (JLP) DABIGATRAN DABIGATRAN DEBIJOHN 10X10 B 65.24 0.65 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
40 B2212 APIDRA SOLOSTAR 100IU/ML INJ (SFA/COL) GLULIS GLULISINE APIDRA SOLOSTAR 3ML VIAL A 19.71 19.71 INJECTION 4 VIAL SFA SANOFI AVENTIS COL COLLINS LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2212 APIDRA SOLOSTAR 100U/ML INJ (SFA) INSULIN GLULISINE INSULIN GLULISINE APIDRA SOLOSTAR 3ML VIAL A 19.71 19.7078 VIAL 2 VIAL SFA SANOFI AVENTIS COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
42 B2212 APIDRA SOLOSTAR 100U/ML INJ (SFA) INSULIN GLULISINE INSULIN GLULISINE APIDRA SOLOSTAR 3ML VIAL A 19.71 19.71 VIAL 2 VIAL SFA SANOFI COL AVENTA BARBADOS B 682008 INSULINS 2026-04-01 2028-03-31 SC 6 INSULINS
40 B2213 APIDRA 100U/ML INJ (SFA/COL) GLULISINE GLULISINE APIDRA 10ML VIAL A 54.37 54.37 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 B2213 APIDRA 100U/ML INJ (SFA) INSULIN GLULISINE INSULIN GLULISINE APIDRA 10ML VIAL A 54.37 54.3665 VIAL 5 VIAL SFA SANOFI AVENTIS COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
42 B2213 APIDRA 100U/ML INJ (SFA) INSULIN GLULISINE INSULIN GLULISINE APIDRA 10ML VIAL A 54.37 54.37 VIAL 5 VIAL SFA SANOFI COL AVENTA BARBADOS B 682008 INSULINS 2026-04-01 2028-03-31 SC 6 INSULINS
40 B2214 NOVORAPID FLEXPENS 100U/ML (NOV/COL) ASPART ASPART NOVORAPID FLEXPENS 5X3ML A 88.35 17.67 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 B2214 NOVORAPID FLEXPENS 100U/ML INJ (NOV) INSULIN ASPART INSULIN ASPART NOVORAPID FLEXPENS 5X3ML A 88.35 17.67 BOX 2 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS