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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 B2221 HUMULIN-R 100U/ML INJ (LIL/STO) INSULIN RAPID INSULIN RAPID HUMULIN-R 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
40 B2222 HUMULIN-R CARTRIDGE INJ (LIL/STO) INSULIN RA INSULIN RAPID HUMULIN-R CARTRIDGE 5X3ML C 43.30 8.66 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
40 B2223 NOVOLIN-R 100U/ML INJ (NOV/COL) INSULIN RAPID INSULIN RAPID NOVOLIN-R 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 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
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