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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
41 B6211 GLYXAMBI 25MG|5MG TAB (BOE) EMPAGL (C) EMPAGLIFLOZIN|LINAGLIPTIN GLYXAMBI 30'S C 118.79 3.9597 TAB 0 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 682005 DIPEPTIDYL PEPTIDASE INHIBITORS 2024-04-01 2026-03-31 ORAL 0 DIPEPTIDYL PEPTIDASE INHIBITORS 2024-01-02