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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 4582A BERIATE 500IU INJ (CSL/AHI) FACTOR VIII FACTOR VIII BERIATE 10ML VIAL BQ 244.65 244.65 INJECTION 0 VIAL CSL CSL BEHRING AG AHI ARMSTRONG HEALTHCARE INC 202816 HEMOSTATICS 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 4582A BERIATE 500IU INJ (CSL) FACTOR VIII (BQ) FACTOR VIII BERIATE 10ML VIAL BQ 244.65 244.6492 VIAL 12 VIAL CSL CSL BEHRING AG AHI ARMSTRONG HEALTHCARE INC 202816 HEMOSTATICS 2024-04-01 2026-03-31 IV 0 HEMOSTATICS
40 4582P HEMOREL A 500IU INJ (RLS/AHI) FACTOR VIII FACTOR VIII HEMOREL A 500IU VIAL BQ 330.28 330.28 INJECTION 0 VIAL RLS RELIANCE LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 202816 HEMOSTATICS 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 4582P HEMOREL A 500IU INJ (RLS) FACTOR VI (BQ) FACTOR VIII HEMOREL A 500IU VIAL BQ 305.81 305.8115 VIAL 12 VIAL RLS RELIANCE LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 202816 HEMOSTATICS 2024-04-01 2026-03-31 IV 0 HEMOSTATICS
41 4582Q XYNTHA 500IU INJ (PFI) FACTOR VIII (C) FACTOR VIII XYNTHA 500IU VIAL C 1065.88 1065.882 VIAL 12 VIAL PFI PFIZER CORPORATION STO BRYDEN STOKES LTD 202816 HEMOSTATICS 2024-04-01 2026-03-31 IV 0 HEMOSTATICS