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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 12011 COSOPT 2% | 0.5% EYE DR (MSD/STO) DORZOLAMIDE | TIMOLOL DORZOLAMIDE|TIMOLOL COSOPT 5ML C 24.76 24.76 EYE DROP 0 BOTT MSD MERCK SHARP & DOHME (I.A.) CORP STO BRYDEN STOKES LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 12011 COSOPT 2%|0.5% EYE DR (MSD/STO) DORZOLA (C) DORZOLAMIDE|TIMOLOL COSOPT 5ML C 24.76 24.76 EYE DROP MSD MERCK SHARP & DOHME (I.A.) CORP STO BRYDEN STOKES LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-04-01 2022-12-31 Delete from contract OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-12-31
40 12012 GLAUCOTENSIL TD 2% | 0.5% EYE DR (LPO/COL) DORZ DORZOLAMIDE|TIMOLOL GLAUCOTENSIL TD 5ML A 12.23 12.23 EYE DROP 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 12012 GLAUCOTENSIL TD 2%|0.5% EYE DR (LPO) DORZOLAMIDE|TIMOLOL DORZOLAMIDE|TIMOLOL GLAUCOTENSIL TD 5ML A 13.46 13.4557 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2024-04-01 2026-03-31 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
42 12012 GLAUCOTENSIL TD 2%|0.5% EYE DR (LPO) DORZOLAMIDE|TIMOLOL DORZOLAMIDE|TIMOLOL GLAUCOTENSIL TD 5ML B 19.03 19.03 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL AVENTA BARBADOS B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2026-04-01 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
40 1201Q DORZOL-T 2% | 0.5% EYE DR (CIR/AHI) DORZOLAMIDE DORZOLAMIDE|TIMOLOL DORZOL-T 10ML A 21.61 21.61 EYE DROP 1 BOTT CIR CIRON PHARMA AHI ARMSTRONG HEALTHCARE INC B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 Ophthalmic 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 1201S ENDOR PLUS 2%|0.5% EYE DR (SYP) DORZOLAMIDE|TIMOLOL DORZOLAMIDE|TIMOLOL ENDOR PLUS 5ML A 11.69 11.6888 BOTT 1 BOTT SYP SYAASH PHARMACEUTICALS PSB PHARMACEUTICAL SOLUTIONS BARBA B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2024-04-01 2026-03-31 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
42 1201T ENDOR PLUS 2%|0.5% EYE DR (SYP) DORZOLAMIDE|TIMOLOL DORZOLAMIDE|TIMOLOL ENDOR PLUS 5ML A 12.48 12.48 BOTT 1 BOTT SYP SYAASH PHARMACEUTICALS PSB PHARMACEUTICAL SOLUTIONS BARBA B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2026-04-01 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS