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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 36551 BRIXIA 0.05% EYE DR (LPO/COL) AZELASTINE AZELASTINE BRIXIA 6ML A 6.25 6.25 EYE DROP 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5202 ANTIALLERGIC AGENTS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 36551 BRIXIA 0.05% EYE DR (LPO) AZELASTINE AZELASTINE BRIXIA 6ML A 6.88 6.8774 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5202 ANTIALLERGIC AGENTS 2024-04-01 2026-03-31 OPHTHALMIC 6 ANTIALLERGIC AGENTS
42 36551 BRIXIA 0.05% EYE DR (LPO) AZELASTINE AZELASTINE BRIXIA 6ML A 19.03 19.03 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL AVENTA BARBADOS 5202 ANTIALLERGIC AGENTS 2026-04-01 OPHTHALMIC 6 ANTIALLERGIC AGENTS