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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 B2216 HUMALOG 100U/ML INJ (LIL) LISPRO INSULIN LISPRO HUMALOG 10ML VIAL A 59.69 59.6944 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
41 B2217 HUMALOG DISP. PEN 100U/ML INJ (LIL) LISP (C) INSULIN LISPRO HUMALOG DISP. PEN 5X3ML C 122.79 24.5573 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
41 B2218 HUMALOG CARTRIDGE 100U/ML INJ (LIL) INSULIN LISPRO (C) INSULIN LISPRO HUMALOG CARTRIDGE 5X3ML C 105.28 21.0561 VIAL 5 BOX LIL ELI LILLY S.A.(PUERTO RICO BRA) STO BRYDEN STOKES LTD 682008 INSULINS 2024-04-01 2026-03-31 SC 6 INSULINS