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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 B441L TRIVERAM 5MG|20MG|5MG TAB (SER) AM (C) AMLODIPINE|ATORVASTATIN|PERINDOPRIL TRIVERAM 30'S C 63.76 2.13 TAB SER LES LABORATOIRES SERVIER STO BRYDEN STOKES LTD 243204 ACE INHIBITORS 2026-04-01 Add to Contract as Cat C ORAL ACE INHIBITORS 2026-04-07
42 B441M TRIVERAM 10MG|20MG|10MG TAB (SER) (C) AMLODIPINE|ATORVASTATIN|PERINDOPRIL TRIVERAM 30'S C 69.93 2.33 TAB SER LES LABORATOIRES SERVIER STO BRYDEN STOKES LTD 243204 ACE INHIBITORS 2026-04-01 Add to Contract as Cat C ORAL ACE INHIBITORS 2026-04-07
42 B441N TRIVERAM 5MG|20MG|10MG TAB (SER) A (C) AMLODIPINE|ATORVASTATIN|PERINDOPRIL TRIVERAM 30'S C 66.70 2.22 TAB SER LES LABORATOIRES SERVIER STO BRYDEN STOKES LTD 243204 ACE INHIBITORS 2026-04-01 Add to Contract as Cat C ORAL ACE INHIBITORS 2026-04-07
42 B441P TRIVERAM 5MG|10MG|5MG TAB (SER) AM (C) AMLODIPINE|ATORVASTATIN|PERINDOPRIL TRIVERAM 30'S C 60.82 2.03 TAB SER LES LABORATOIRES SERVIER STO BRYDEN STOKES LTD 243204 ACE INHIBITORS 2026-04-01 Add to Contract as Cat C ORAL ACE INHIBITORS 2026-04-07