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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 3294S PREPRATION H MULTI-SYMPTOM 0.25%|1% CR (GSK) PHENYLEPHRINE|P GLYCERINE|PHENYLEPHRINE|PRAMOXINE PREPRATION H MULTI-SYMPTOM 26G A 13.35 13.347 TUBE 1 BOX GSK GLAXOSMITHKLINE COL COLLINS LTD 8406 ANTI-INFLAMMATORY AGENTS, TOPICAL 2024-04-01 2026-03-31 TOPICAL 0 ANTI-INFLAMMATORY AGENTS, TOPICAL
40 40919 GLYCEROL ADULT 4G SUPPOS (MTP/COL) GLYCERINE GLYCERINE GLYCEROL ADULT 12'S A 4.62 0.39 SUPPOSITORY 12 SUPP MTP MARTINDALE PHARMACEUTICALS COL COLLINS LTD 5612 CATHARTICS AND LAXATIVES 2022-06-02 2024-03-31 Add to Contract as Cat A RECTAL 6 GASTROINTESTINAL DRUGS 2022-06-02
40 4091R GLYCERINE ADULT 2G SUPPOS (FLE/AHI) GLYCERINE GLYCERINE GLYCERINE ADULT 12'S A 2.47 0.21 SUPPOSITORY 12 SUPP FLE C.B. FLEET & CO. INC., AHI ARMSTRONG HEALTHCARE INC 5612 CATHARTICS AND LAXATIVES 2022-04-01 2024-03-31 RECTAL 6 GASTROINTESTINAL DRUGS
42 4091S GLYCEROL 4G SUPPOS (MTP) GLYCERINE GLYCERINE GLYCEROL 12'S A 9.46 0.79 SUPP 12 BLIS MTP MARTINDALE PHARMACEUTICALS AHI ARMSTRONG HEALTHCARE INC 5612 CATHARTICS AND LAXATIVES 2026-04-01 RECTAL 6 CATHARTICS AND LAXATIVES
40 4092H GLYCERINE PAED 1G SUPPOS (FLE/AHI) GLYCERINE GLYCERINE GLYCERINE PAED 12'S A 2.88 0.24 SUPPOSITORY 12 SUPP FLE C.B. FLEET & CO. INC., AHI ARMSTRONG HEALTHCARE INC 5612 CATHARTICS AND LAXATIVES 2022-04-01 2024-03-31 RECTAL 0 GASTROINTESTINAL DRUGS
42 4092J GLYCEROL 1G SUPPOS (MTP) GLYCERINE GLYCERINE GLYCEROL 12'S A 7.96 0.66 SUPP 12 BLIS MTP MARTINDALE PHARMACEUTICALS AHI ARMSTRONG HEALTHCARE INC 5612 CATHARTICS AND LAXATIVES 2026-04-01 RECTAL 0 CATHARTICS AND LAXATIVES
42 4092K GLYCEROL 2G SUPPOS (MTP) GLYCERINE GLYCERINE GLYCEROL 12'S A 8.62 0.72 SUPP 12 BLIS MTP MARTINDALE PHARMACEUTICALS AHI ARMSTRONG HEALTHCARE INC 5612 CATHARTICS AND LAXATIVES 2026-04-01 RECTAL 0 CATHARTICS AND LAXATIVES
42 46319 DESIRE 82G GEL (HEA) GLYCERINE GLYCERINE DESIRE 82G B 3.23 3.23 TUBE 1 TUBE HEA HEALTH 2000 INC AHI ARMSTRONG HEALTHCARE INC 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2026-04-01 Price Change TOPICAL 0 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2025-10-31
42 4631AC LUBRI-EZE GEL TUBE (INF) LUBRICATING JELLY GLYCERINE LUBRI-EZE GEL 30G B 2.69 2.69 TUBE 1 TUBE INF INFOCUS REMEDIES PVT RXP RX PRO INC 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2026-04-01 TOPICAL 0 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS
42 4631AD DESIRE JELLY (HEA) LUBRICATING JELLY GLYCERINE DESIRE 82G B 3.23 3.23 TUBE 0 TUBE HEA HEALTH 2000 INC CWS CAPSULE WHOLESALE 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2026-04-01 Add to Contract as Cat B TOPICAL 0 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2026-01-26
42 4631AE DESIRE GEL (HEA) GLYCERINE GLYCERINE DESIRE 82G B 3.23 3.23 TUBE 0 HEA HEALTH 2000 INC STO BRYDEN STOKES LTD 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2026-04-01 Add to Contract as Cat B VAGINAL 0 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2026-02-27
40 4631B AQUAGEL (ECO/COL) LUBRICATING JELLY GLYCERINE AQUAGEL 82G B 3.29 3.29 0 TUBE ECO ECOLAB LTD COL COLLINS LTD 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2022-04-01 2024-03-31 TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS
40 4631Y DESIRE JELLY (HEA/RXP) LUBRICATING JELLY GLYCERINE DESIRE 82G B 3.26 3.26 JELLY 0 TUBE HEA HEALTH 2000 INC RXP RX PRO INC 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2022-04-01 2024-03-31 TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS
40 4701AP TEARS NATURALE FORTE EYE DR (ALC/AHI) DEXTRAN | GLYCERINE | HYPROMELLOSE DEXTRAN|GLYCERINE|HYPROMELLOSE TEARS NATURALE FORTE 15ML C 13.32 13.32 EYE DROP 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 4701AV REFRESH OPTIVE GEL 1% | 0.9% EYE DR (ALL/COL) CARBOXYMETHYLCELLULOSE | GLYCERINE CARBOXYMETHYLCELLULOSE|GLYCERINE REFRESH OPTIVE GEL 10ML C 12.91 12.91 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701AV REFRESH OPTIVE GEL 1%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULO (C) CARBOXYMETHYLCELLULOSE|GLYCERINE REFRESH OPTIVE GEL 10ML C 12.91 12.912 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
42 4701AV REFRESH OPTIVE GEL 1%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULO CARBOXYMETHYLCELLULOSE|GLYCERINE REFRESH OPTIVE GEL 10ML C 12.91 12.91 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL AVENTA BARBADOS 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
40 4701K OPTIVE .05%C/0.9%G EYE DR (ALL/COL) CARBOXY/G CARBOXYMETHYLCELLULOSE|GLYCERINE OPTIVE 15ML C 13.59 13.59 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701K OPTIVE 0.5%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULOSE|GLYCERI (C) CARBOXYMETHYLCELLULOSE|GLYCERINE OPTIVE 15ML C 13.59 13.5916 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
40 99918 GLYCERINE & THYMOL (CAR/COL) GLYCERINE & THYMOL GLYCERINE & THYMOL 2 LITRES B 39.42 0.02 0 ML CAR CARLISLE LABORATORIES LTD COL COLLINS LTD 5228 MOUTH WASHES AND GARGLES 2022-04-01 2024-03-31 TOPICAL 0 EYE, EAR, NOSE AND THROAT PREPARATIONS