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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 5581V HISTAL DM SYR (CAR/COL) GUAIFE/DEXTRO DEXTROMETHORPHAN|GUAIFENESIN HISTAL DM 2 LITRES B 76.11 0.04 SYRUP 0 ML CAR CARLISLE LABORATORIES LTD COL COLLINS LTD 4816 EXPECTORANTS 2022-05-06 2024-03-31 Add to Contract as Cat B Oral 0 RESPIRATORY TRACT AGENTS 2022-05-06
41 5581V HISTAL DM SYR (CAR) GUAIFE/DEXTRO (B) DEXTROMETHORPHAN|GUAIFENESIN HISTAL DM 2 LITRES B 92.42 0.0462 ML 0 BOTT CAR CARLISLE LABORATORIES LTD COL COLLINS LTD 4816 EXPECTORANTS 2024-04-01 2026-03-31 ORAL 0 EXPECTORANTS
42 5581V HISTAL DM 3MG/ML|20MG/ML SYR (CAR) DEXTROMETHORPHAN|GUAIFENE DEXTROMETHORPHAN|GUAIFENESIN HISTAL DM 2 LITRES B 108.73 0.05 ML 100 BOTT CAR CARLISLE LABORATORIES LTD COL AVENTA BARBADOS 4816 EXPECTORANTS 2026-04-01 ORAL 0 EXPECTORANTS