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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 A3926 RELVAR ELLIPTA 100MCG | 25MCG INHR (GSK/COL) FL FLUTICASONE|VILANTEROL RELVAR ELLIPTA 30 DOSES A 41.67 41.67 INHALER 1 INHR GSK GLAXOSMITHKLINE COL COLLINS LTD B 4892 RESPIRATORY AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 ORAL INHALATION 6 RESPIRATORY TRACT AGENTS
41 A3926 RELVAR ELLIPTA 100MCG|25MCG INHR (GSK) F FLUTICASONE|VILANTEROL RELVAR ELLIPTA 30 DOSES A 43.33 43.3301 INHR 1 BOX GSK GLAXOSMITHKLINE COL COLLINS LTD B 4892 RESPIRATORY AGENTS MISCELLANEOUS 2024-04-01 2026-03-31 ORAL INHALATION 6 RESPIRATORY AGENTS MISCELLANEOUS
42 A3926 RELVAR ELLIPTA 100MCG|25MCG INHR (GSK) F FLUTICASONE|VILANTEROL RELVAR ELLIPTA 30 DOSES A 45.48 45.48 INHR 1 BOX GSK GLAXOSMITHKLINE COL AVENTA BARBADOS B 4892 RESPIRATORY AGENTS MISCELLANEOUS 2026-04-01 ORAL INHALATION 6 RESPIRATORY AGENTS MISCELLANEOUS
40 A3969 RELVAR ELLIPTA 200MCG | 25MCG INHR (GSK/COL) FL FLUTICASONE|VILANTEROL RELVAR ELLIPTA 30 DOSES A 44.25 44.25 INHALER 1 INHR GSK GLAXOSMITHKLINE COL COLLINS LTD B 4892 RESPIRATORY AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 ORAL INHALATION 6 RESPIRATORY TRACT AGENTS
41 A3969 RELVAR ELLIPTA 200MCG|25MCG INHR (GSK) F FLUTICASONE|VILANTEROL RELVAR ELLIPTA 30 DOSES A 46.02 46.0212 INHR 1 BOX GSK GLAXOSMITHKLINE COL COLLINS LTD B 4892 RESPIRATORY AGENTS MISCELLANEOUS 2024-04-01 2026-03-31 ORAL INHALATION 6 RESPIRATORY AGENTS MISCELLANEOUS
42 A3969 RELVAR ELLIPTA 200MCG|25MCG INHR (GSK) FLUTICASONE|VILANTERO FLUTICASONE|VILANTEROL RELVAR ELLIPTA 30 DOSES A 48.33 48.33 INHR 1 BOX GSK GLAXOSMITHKLINE COL AVENTA BARBADOS B 4892 RESPIRATORY AGENTS MISCELLANEOUS 2026-04-01 ORAL INHALATION 6 RESPIRATORY AGENTS MISCELLANEOUS