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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 73619 RECORMON PREFILL 4000U INJ (ROC/AHI) EPOIETIN EPOIETIN BETA RECORMON PREFILL 6X4000U BQ 217.41 36.24 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 73619 RECORMON PREFILL 4000U INJ (ROC) EPOIE B (BQ) EPOIETIN BETA RECORMON PREFILL 6X4000U BQ 217.41 36.2353 VIAL 7 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2024-04-01 2026-03-31 IV 0 HEMATOPOIETIC
40 7361E MIRCERA PREFILL 100MCG INJ (ROC/AHI) EPOIETIN EPOIETIN BETA MIRCERA PREFILL 100MCG SYN BQ 342.51 342.51 INJECTION 0 PFS ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 7361E MIRCERA PREFILL 100MCG INJ (ROC) EPOIETI (BQ) EPOIETIN BETA MIRCERA PREFILL 100MCG SYN BQ 342.51 342.5088 PFS 7 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2024-04-01 2026-03-31 IV 0 HEMATOPOIETIC
40 7362B MIRCERA PREFILL 75MCG INJ (ROC/AHI) EPOIETIN BETA EPOIETIN BETA MIRCERA PREFILL 75MCG SYRN BQ 244.65 244.65 INJECTION 0 PFS ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 7362B MIRCERA PREFILL 75MCG INJ (ROC) EPOIETIN BETA (BQ) EPOIETIN BETA MIRCERA PREFILL 75MCG SYRN BQ 244.65 244.6492 PFS 7 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2024-04-01 2026-03-31 IV 6 HEMATOPOIETIC
40 7362F MIRCERA PREFILL 50MCG INJ (ROC/AHI) EPOIETIN EPOIETIN BETA MIRCERA PREFILL 50MCG SYRN BQ 171.25 171.25 INJECTION 0 PFS ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 7362F MIRCERA PREFILL 50MCG INJ (ROC) EPOIETIN (BQ) EPOIETIN BETA MIRCERA PREFILL 50MCG SYRN BQ 171.25 171.2544 PFS 7 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2024-04-01 2026-03-31 IV 0 HEMATOPOIETIC
40 7363A MIRCERA PREFILL 200MCG INJ (ROC/AHI) EPOIETIN EPOIETIN BETA MIRCERA PREFILL 200MCG SYN BQ 685.02 685.02 INJECTION 0 PFS ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 7363A MIRCERA PREFILL 200MCG INJ (ROC) EPOIETI EPOIETIN BETA MIRCERA PREFILL 200MCG SYN BQ 685.02 685.0176 PFS 7 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2024-04-01 2026-03-31 IV 0 HEMATOPOIETIC