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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 58022 IMMUNINE 600IU INJ (BAX/STO) FACTOR IX FACTOR IX IMMUNINE 600IU VIAL BQ 608.58 608.58 INJECTION 0 VIAL BAX BAXTER EXPORT CORP. STO BRYDEN STOKES LTD 202816 HEMOSTATICS 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 58022 IMMUNINE 600IU INJ (BAX) FACTOR IX FACTOR IX IMMUNINE 600IU VIAL BQ 634.35 634.3481 VIAL 0 VIAL BAX BAXTER EXPORT CORP. STO BRYDEN STOKES LTD 202816 HEMOSTATICS 2024-04-01 2026-03-31 IV 0 HEMOSTATICS
42 58022 IMMUNINE 600IU INJ (BAX) FACTOR IX FACTOR IX IMMUNINE 600IU VIAL BQ 634.35 634.35 VIAL 0 VIAL BAX BAXTER EXPORT CORP. STO BRYDEN STOKES LTD 202816 HEMOSTATICS 2026-04-01 IV 0 HEMOSTATICS
42 58027 FACTORCEL IX 600IU INJ (INP) FACTOR IX FACTOR IX FACTORCEL IX 600IU VIAL BQ 951.71 951.71 VIAL 0 VIAL INP INTAS PHARMACEUTICALS LTD AHI ARMSTRONG HEALTHCARE INC 2016 HEMATOPOIETIC 2026-04-01 IV 0 HEMATOPOIETIC