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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 2362A TRIASOL 1% EYE DR (ASL) TROPICAMIDE TROPICAMIDE TRIASOL 10ML B 11.55 11.55 BOTT 1 BOTT ASL ASHFORD LABORATORIES LTD PHA PHARMACY SALES CARIBBEAN 5224 EENT MYDRIATICS 2026-04-01 2028-03-31 OPHTHALMIC 0 EENT MYDRIATICS 2025-12-04
40 2362G TROPICAMIDE 1% EYE DR (AKI/AHI) TROPICAMIDE TROPICAMIDE 15ML A 39.20 39.20 EYE DROP 1 BOTT AKI AKORN INC. AHI ARMSTRONG HEALTHCARE INC 5224 EENT MYDRIATICS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 2362J TROPICAMIDE 1% EYE DR (AKI) TROPICAMIDE TROPICAMIDE 15ML A 44.06 44.064 BOTT 1 BOTT AKI AKORN INC. AHI ARMSTRONG HEALTHCARE INC 5224 EENT MYDRIATICS 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT MYDRIATICS
41 23716 XYLOMETAZOLINE 0.1% NASAL DR (KWA) XYLOMETAZOLINE XYLOMETAZOLINE 15ML A 3.56 3.561 BOTT 1 BOX KWA KWALITY PHARMACEUTICALS ATB ANSA TRADING BARBADOS LTD 5232 EENT VASOCONSTRICTORS 2024-04-01 2026-03-31 NASAL 0 EENT VASOCONSTRICTORS
40 23717 XYLOMETAZOLINE 0.1% NASAL DR (CIR/AHI) XYLOMETAZOLINE XYLOMETAZOLINE 10ML A 2.66 2.66 NASAL DROP 1 BOTT CIR CIRON PHARMA AHI ARMSTRONG HEALTHCARE INC 5232 EENT VASOCONSTRICTORS 2022-04-01 2022-09-30 NASAL 0 EYE, EAR, NOSE AND THROAT PREPARATIONS 2022-03-29
40 2371E OTRIVINE 0.1% NASAL DR (GSK/COL) XYLOMETAZOLI XYLOMETAZOLINE OTRIVINE 10ML A 5.79 5.79 NASAL DROP 1 BOTT GSK GLAXOSMITHKLINE COL COLLINS LTD 5232 EENT VASOCONSTRICTORS 2022-04-01 2024-03-31 NASAL 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 2371E OTRIVINE 0.1% NASAL DR (GSK) XYLOMETAZOL (C) XYLOMETAZOLINE OTRIVINE 10ML C 6.09 6.089 BOTT 1 BOTT GSK GLAXOSMITHKLINE COL COLLINS LTD 5232 EENT VASOCONSTRICTORS 2024-04-01 2026-03-31 NASAL 0 EENT VASOCONSTRICTORS
42 2371E OTRIVINE 0.1% NASAL DR (GSK) XYLOMETAZOL XYLOMETAZOLINE OTRIVINE 10ML C 6.39 6.39 BOTT 1 BOTT GSK GLAXOSMITHKLINE COL AVENTA BARBADOS 5232 EENT VASOCONSTRICTORS 2026-04-01 2028-03-31 NASAL 0 EENT VASOCONSTRICTORS
40 2371H OXOZOLIN 0.05% NASAL DR (ARP/AHI) OXYMETAZOLI OXYMETAZOLINE OXOZOLIN 10ML A 4.57 4.57 NASAL DROP 1 BOTT ARP ARISTOPHARMA LTD AHI ARMSTRONG HEALTHCARE INC 5232 EENT VASOCONSTRICTORS 2022-04-01 2024-03-31 NASAL 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 2371H OXOZOLIN 0.05% NASAL DR (ARP) OXYME OXYMETAZOLINE OXOZOLIN 10ML A 4.95 4.9473 BOTT 1 BOTT ARP ARISTOPHARMA LTD AHI ARMSTRONG HEALTHCARE INC 5232 EENT VASOCONSTRICTORS 2024-04-01 2026-03-31 NASAL 0 EENT VASOCONSTRICTORS
41 2371M AFRIN 0.05% NASAL DR (BSP) OXYMETAZOLINE (C) OXYMETAZOLINE AFRIN 15ML C 13.46 13.4557 BOTT 1 BOTT BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 5232 EENT VASOCONSTRICTORS 2024-04-01 2026-03-31 NASAL 0 EENT VASOCONSTRICTORS
42 2371P XYLOMETAZOLINE 0.1% NASAL DR (FSB) XYLOMETAZOLINE XYLOMETAZOLINE 15ML A 1.50 1.50 BOTT 1 FSB FLAGSHIP BIOTECH STO BRYDEN STOKES LTD 5232 EENT VASOCONSTRICTORS 2026-04-01 2028-03-31 NASAL 0 EENT VASOCONSTRICTORS 2026-03-05
40 23728 OTRIVINE MDI 0.1% NASAL SP (GSK/COL) XYLOMETA XYLOMETAZOLINE OTRIVINE MDI 10ML C 4.38 4.38 NASAL SPRAY 0 BOTT GSK GLAXOSMITHKLINE COL COLLINS LTD 5232 EENT VASOCONSTRICTORS 2022-04-01 2024-03-31 NASAL 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 23728 OTRIVINE MDI 0.1% NASAL SP (GSK) XYLOMET (C) XYLOMETAZOLINE OTRIVINE MDI 10ML C 4.59 4.594 BOTT 1 BOTT GSK GLAXOSMITHKLINE COL COLLINS LTD 5232 EENT VASOCONSTRICTORS 2024-04-01 2026-03-31 NASAL 0 EENT VASOCONSTRICTORS
42 23728 OTRIVINE MDI 0.1% NASAL SP (GSK) XYLOMET XYLOMETAZOLINE OTRIVINE MDI 10ML C 4.59 4.59 BOTT 1 BOTT GSK GLAXOSMITHKLINE COL AVENTA BARBADOS 5232 EENT VASOCONSTRICTORS 2026-04-01 2028-03-31 NASAL 0 EENT VASOCONSTRICTORS
40 2372K OTRIVINE 0.1% NASAL SP (GSK/COL) XYLOMETAZOLI XYLOMETAZOLINE OTRIVINE 10ML C 4.78 4.78 NASAL SPRAY 0 BOTT GSK GLAXOSMITHKLINE COL COLLINS LTD 5232 EENT VASOCONSTRICTORS 2022-04-01 2024-03-31 NASAL 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 2372K OTRIVINE 0.1% NASAL SP (GSK) XYLOMETAZOL (C) XYLOMETAZOLINE OTRIVINE 10ML C 5.03 5.0289 BOTT 1 BOTT GSK GLAXOSMITHKLINE COL COLLINS LTD 5232 EENT VASOCONSTRICTORS 2024-04-01 2026-03-31 NASAL 0 EENT VASOCONSTRICTORS
42 2372K OTRIVINE 0.1% NASAL SP (GSK) XYLOMETAZOL XYLOMETAZOLINE OTRIVINE 10ML C 5.27 5.27 BOTT 1 BOTT GSK GLAXOSMITHKLINE COL AVENTA BARBADOS 5232 EENT VASOCONSTRICTORS 2026-04-01 2028-03-31 NASAL 0 EENT VASOCONSTRICTORS
41 2372T XYLOMETAZOLINE 0.1% NASAL SP (KWA) XYLOMETAZOLINE XYLOMETAZOLINE 10ML A 2.96 2.963 BOTT 1 BOTT KWA KWALITY PHARMACEUTICALS ATB ANSA TRADING BARBADOS LTD 5232 EENT VASOCONSTRICTORS 2024-04-01 2026-03-31 NASAL 0 EENT VASOCONSTRICTORS
40 2372U XYLOMETAZOLINE 0.1% NASAL SP (FSB/ATB) XYLOMETAZOLINE XYLOMETAZOLINE 10ML A 3.53 3.53 NASAL SPRAY 1 BOTT FSB FLAGSHIP BIOTECH ATB ANSA TRADING BARBADOS LTD 5232 EENT VASOCONSTRICTORS 2022-04-01 2024-03-31 NASAL 0 EYE, EAR, NOSE AND THROAT PREPARATIONS