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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 B2231 HUMULIN-N 100U/ML INJ (LIL/STO) INSULIN ISOPH INSULIN ISOPHANE HUMULIN-N 10ML VIAL A 14.92 14.92 INJECTION 5 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2231 HUMULIN-N 100U/ML INJ (LIL) INSULIN ISOP INSULIN ISOPHANE HUMULIN-N 10ML VIAL A 20.36 20.3602 VIAL 5 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B2232 NOVOLIN-N 100U/ML INJ (NOV/COL) INSULIN ISOPH INSULIN ISOPHANE NOVOLIN-N 10ML VIAL A 11.96 11.96 INJECTION 5 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2232 NOVOLIN-N 100U/ML INJ (NOV) INSULIN ISOP INSULIN ISOPHANE NOVOLIN-N 10ML VIAL A 11.96 11.9606 VIAL 5 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
42 B2232 NOVOLIN-N 100U/ML INJ (NOV) INSULIN ISOPHANE INSULIN ISOPHANE NOVOLIN-N 10ML VIAL A 11.96 11.96 VIAL 5 VIAL NOV NOVO NORDISK A/S COL AVENTA BARBADOS B 682008 INSULINS 2026-04-01 SC 6 INSULINS
40 B2234 HUMILIN-N CARTRIDGE 100U/ML INJ (LIL/STO) ISO INSULIN ISOPHANE HUMILIN-N CARTRIDGE 5X3ML C 59.42 11.88 INJECTION VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD 682008 INSULINS 2022-07-11 2024-03-31 Add to Contract as Cat C SC HORMONES AND SYNTHETIC SUBSTITUTES 2022-07-11
41 B2234 HUMULIN-N CARTRIDGE 100U/ML INJ (LIL) INSULIN ISOPHANE (C) INSULIN ISOPHANE HUMULIN-N CARTRIDGE 5X3ML C 56.05 11.2104 VIAL 5 BOX LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B2251 HUMULIN 70% | 30% INJ (LIL/STO) INSULIN ISOPHANE | INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR HUMULIN 10ML VIAL A 14.92 14.92 INJECTION 5 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2251 HUMULIN 70%|30% INJ (LIL) INSULIN ISOPHANE|INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR HUMULIN 10ML VIAL A 21.23 21.23 VIAL 5 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2024-04-01 2024-10-04 SC 6 INSULINS 2024-08-23
40 B2252 NOVOLIN 70% | 30% INJ (NOV/COL) INSULIN ISOPHANE | INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR NOVOLIN 10ML VIAL A 11.96 11.96 INJECTION 5 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B2252 NOVOLIN 70%|30% INJ (NOV) INSULIN ISOPHANE|INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR NOVOLIN 10ML VIAL A 11.96 11.9606 VIAL 5 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
42 B2252 NOVOLIN 70%|30% INJ (NOV) INSULIN ISOPHANE|INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR NOVOLIN 10ML VIAL A 11.96 11.96 VIAL 5 VIAL NOV NOVO NORDISK A/S COL AVENTA BARBADOS B 682008 INSULINS 2026-04-01 SC 6 INSULINS
41 B2258 HUMALOG 75%|25% INJ (LIL) INSULIN ISOPHANE|INSULIN REGULAR (C) INSULIN ISOPHANE|INSULIN RAPID HUMALOG 5X3ML C 134.69 26.9386 VIAL 0 BOX LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD 682008 INSULINS 2024-04-01 2026-03-31 SC 0 INSULINS
40 B225A HUMULIN CARTRIDGE 70% | 30% INJ (LIL/STO) INSULIN ISOPHANE | INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR HUMULIN CARTRIDGE 5X3ML A 47.03 9.41 INJECTION 5 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 6 HORMONES AND SYNTHETIC SUBSTITUTES
41 B225A HUMULIN CARTRIDGE 70%|30% INJ (LIL) INSULIN ISOPHANE|INSULIN (C) INSULIN ISOPHANE|INSULIN REGULAR HUMULIN CARTRIDGE 5X3ML C 52.41 52.41 CAR 5 VIAL LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
40 B225B NOVOLIN PENFIL 70% | 30% INJ (NOV/COL) INSULIN ISOPHANE | INSULIN REGULAR INSULIN ISOPHANE|INSULIN REGULAR NOVOLIN PENFIL 5X3ML C 61.19 12.24 INJECTION 0 VIAL NOV NOVO NORDISK A/S COL COLLINS LTD B 682008 INSULINS 2022-04-01 2024-03-31 SC 0 HORMONES AND SYNTHETIC SUBSTITUTES
41 B225B NOVOLIN PENFIL 70%|30% INJ (NOV) INSULIN ISOPHANE|INSULIN RE (C) INSULIN ISOPHANE|INSULIN REGULAR NOVOLIN PENFIL 5X3ML C 61.16 12.2325 VIAL 5 BOX NOV NOVO NORDISK A/S COL COLLINS LTD 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS
42 B225B NOVOLIN PENFIL 70%|30% INJ (NOV) INSULIN ISOPHANE|INSULIN RE INSULIN ISOPHANE|INSULIN REGULAR NOVOLIN PENFIL 5X3ML A 61.16 12.23 VIAL 5 VIAL NOV NOVO NORDISK A/S COL AVENTA BARBADOS B 682008 INSULINS 2026-04-01 SC 6 INSULINS
41 B225D HUMALOG KWIKPEN 75%|25% INJ (LIL) INSULIN ISOPHANE|INSULIN R (C) INSULIN ISOPHANE|INSULIN RAPID HUMALOG KWIKPEN 5X3ML C 139.29 27.8574 VIAL 0 BOX LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD B 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS