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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 76712 ACTILYSE 50MG INJ (BOE/STO) ALTEPLASE ALTEPLASE ACTILYSE 2X50MG BQ 4,817.93 2,408.97 INJECTION 0 VIAL BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 201220 THROMBOLYTIC AGENTS 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 76712 ACTILYSE 50MG INJ (BOE) ALTEPLASE (BQ) ALTEPLASE ACTILYSE 2X50MG BQ 5307.23 2653.6143 VIAL 0 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 201220 THROMBOLYTIC AGENTS 2024-04-01 2026-03-31 IV 0 THROMBOLYTIC AGENTS