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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 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 AVENTA BARBADOS B 682008 INSULINS 2026-04-01 2028-03-31 SC 6 INSULINS 2026-04-21
40 B2216 HUMALOG 100U/ML INJ (LIL/STO) LISPRO LISPRO HUMALOG 10ML VIAL A 60.94 60.94 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 B2216 HUMALOG 100U/ML INJ (LIL) LISPRO INSULIN LISPRO HUMALOG 10ML VIAL A 59.69 59.6944 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 B2217 HUMALOG DISP. PEN 100U/ML INJ (LIL/STO) LISPR LISPRO HUMALOG DISP. PEN 5X3ML C 112.13 22.43 INJECTION 0 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 0 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2217 HUMALOG DISP. PEN 100U/ML INJ (LIL) LISP (C) INSULIN LISPRO HUMALOG DISP. PEN 5X3ML C 122.79 24.5573 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 B2218 HUMALOG CARTRIDGE INJ (LIL/STO) LISPRO LISPRO HUMALOG CARTRIDGE 5X3ML C 100.55 20.11 INJECTION 0 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD 682008 INSULINS 2022-04-01 2024-03-31 SC 0 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2218 HUMALOG CARTRIDGE 100U/ML INJ (LIL) INSULIN LISPRO (C) INSULIN LISPRO HUMALOG CARTRIDGE 5X3ML C 105.28 21.0561 VIAL 5 BOX LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B2221 HUMULIN-R 100U/ML INJ (LIL/STO) INSULIN RAPID INSULIN RAPID HUMULIN-R 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 B2221 HUMULIN-R 100U/ML INJ (LIL) INSULIN SHORT ACTING INSULIN REGULAR HUMULIN-R 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 B2222 HUMULIN-R CARTRIDGE INJ (LIL/STO) INSULIN RA INSULIN RAPID HUMULIN-R CARTRIDGE 5X3ML C 43.30 8.66 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 B2222 HUMULIN-R CARTRIDGE 100U/ML INJ (LIL) INSULIN SHORT ACTING (C) INSULIN REGULAR HUMULIN-R CARTRIDGE 5X3ML C 54.56 10.9114 VIAL 5 BOX LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B2223 NOVOLIN-R 100U/ML INJ (NOV/COL) INSULIN RAPID INSULIN RAPID NOVOLIN-R 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 B2223 NOVOLIN-R 100U/ML INJ (NOV) INSULIN SHORT ACTING INSULIN REGULAR NOVOLIN-R 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 2024-04-01
42 B2223 NOVOLIN-R 100U/ML INJ (NOV) INSULIN REGULAR INSULIN REGULAR NOVOLIN-R 10ML VIAL A 11.96 11.96 VIAL 5 VIAL NOV NOVO NORDISK A/S COL AVENTA BARBADOS B 682008 INSULINS 2026-04-01 2028-03-31 SC 6 INSULINS
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
42 B2232 NOVOLIN-N 100U/ML INJ (NOV) INSULIN ISOPHANE INSULIN ISOPHANE NOVOLIN-N 10ML VIAL A 11.96 11.96 VIAL 5 VIAL NOV NOVO NORDISK A/S COL AVENTA BARBADOS B 682008 INSULINS 2026-04-01 2028-03-31 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