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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 4701AV REFRESH OPTIVE GEL 1% | 0.9% EYE DR (ALL/COL) CARBOXYMETHYLCELLULOSE | GLYCERINE CARBOXYMETHYLCELLULOSE|GLYCERINE REFRESH OPTIVE GEL 10ML C 12.91 12.91 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701AV REFRESH OPTIVE GEL 1%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULO (C) CARBOXYMETHYLCELLULOSE|GLYCERINE REFRESH OPTIVE GEL 10ML C 12.91 12.912 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
42 4701AV REFRESH OPTIVE GEL 1%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULO CARBOXYMETHYLCELLULOSE|GLYCERINE REFRESH OPTIVE GEL 10ML C 12.91 12.91 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL AVENTA BARBADOS 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
40 4701K OPTIVE .05%C/0.9%G EYE DR (ALL/COL) CARBOXY/G CARBOXYMETHYLCELLULOSE|GLYCERINE OPTIVE 15ML C 13.59 13.59 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701K OPTIVE 0.5%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULOSE|GLYCERI (C) CARBOXYMETHYLCELLULOSE|GLYCERINE OPTIVE 15ML C 13.59 13.5916 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS