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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 A322FZ PRISTIQ 50MG TAB (PFI/STO) DESVENLAFAXINE DESVENLAFAXINE PRISTIQ 28'S C 95.49 3.41 TABLET 0 TAB PFI PFIZER CORPORATION STO BRYDEN STOKES LTD 28160420 SELECTIVE SEROTONIN REUPTAKE INHIBITORS 2022-04-01 2024-03-31 Oral 0 CENTRAL NERVOUS SYSTEM DRUGS
41 A322FZ PRISTIQ 50MG TAB (PFI) DESVENLAFAXINE (C) DESVENLAFAXINE PRISTIQ 28'S C 96.45 3.4445 TAB 0 BOX PFI PFIZER CORPORATION STO BRYDEN STOKES LTD 28160420 SELECTIVE SEROTONIN REUPTAKE INHIBITORS 2024-04-01 2026-03-31 ORAL 0 SELECTIVE SEROTONIN REUPTAKE INHIBITORS
42 A322FZ PRISTIQ 50MG TAB (PFI) DESVENLAFAXI DESVENLAFAXINE PRISTIQ 28'S C 96.45 3.44 TAB 0 BLIS PFI PFIZER CORPORATION STO BRYDEN STOKES LTD 28160420 SELECTIVE SEROTONIN REUPTAKE INHIBITORS 2026-04-01 ORAL 0 SELECTIVE SEROTONIN REUPTAKE INHIBITORS