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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 B1511 PRADAX 75MG TAB (BOE/STO) DABIGATRAN DABIGATRAN PRADAX 3X10 BQ 88.75 2.96 TABLET 0 TAB BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 6 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1511 PRADAX 75MG TAB (BOE) DABIGATRAN (BQ) DABIGATRAN PRADAX 3X10 BQ 96.64 3.2212 TAB 60 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
40 B1521 PRADAX 110MG TAB (BOE/STO) DABIGATRAN DABIGATRAN PRADAX 3X10 BQ 88.75 2.96 TABLET 0 TAB BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 6 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1521 PRADAX 110MG TAB (BOE) DABIGATRAN (BQ) DABIGATRAN PRADAX 3X10 BQ 96.64 3.2212 TAB 60 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
40 B1524 PRADAX 110MG TAB (BOE/STO) DABIGATRAN DABIGATRAN PRADAX 60'S BQ 177.51 2.96 TABLET 0 TAB BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 6 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1524 PRADAX 110MG TAB (BOE) DABIGATRAN (BQ) DABIGATRAN PRADAX 60'S BQ 193.27 3.2212 TAB 60 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
40 B1531 PRADAX 150MG TAB (BOE/STO) DABIGATRAN DABIGATRAN PRADAX 60'S BQ 177.51 2.96 TABLET 0 TAB BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 6 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1531 PRADAX 150MG TAB (BOE) DABIGATRAN (BQ) DABIGATRAN PRADAX 60'S BQ 193.27 3.2212 TAB 60 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS