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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 36223 PROLOPA 50MG | 200MG TAB (ROC/AHI) BENSERAZIDE | BENSERAZIDE|LEVODOPA PROLOPA 30'S A 40.77 1.36 TABLET 240 TAB ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 283616 DOPAMINE PRECURSORS 2022-04-01 2024-03-31 Oral 6 CENTRAL NERVOUS SYSTEM DRUGS
41 36223 PROLOPA 50MG|200MG TAB (ROC) BENSERAZIDE|LEVODOPA BENSERAZIDE|LEVODOPA PROLOPA 30'S A 30.15 1.005 TAB 240 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 283616 DOPAMINE PRECURSORS 2024-09-27 2026-03-31 ORAL 6 DOPAMINE PRECURSORS 2024-09-27
42 3622V BENKINSON 50MG|200MG CAP (INC) BENSERAZIDE|LEVODOPA BENSERAZIDE|LEVODOPA BENKINSON 20'S A 15.71 0.79 CAP 240 BLIS INC INCEPTA PHARMACEUTICALS LIMITED AHI ARMSTRONG HEALTHCARE INC 283616 DOPAMINE PRECURSORS 2026-04-01 ORAL 6 DOPAMINE PRECURSORS