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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 B2221 HUMULIN-R 100U/ML INJ (LIL) INSULIN SHORT ACTING INSULIN REGULAR HUMULIN-R 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
41 B2222 HUMULIN-R CARTRIDGE 100U/ML INJ (LIL) INSULIN SHORT ACTING (C) INSULIN REGULAR HUMULIN-R CARTRIDGE 5X3ML C 54.56 10.9114 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
41 B2223 NOVOLIN-R 100U/ML INJ (NOV) INSULIN SHORT ACTING INSULIN REGULAR NOVOLIN-R 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 2024-04-01
42 B2223 NOVOLIN-R 100U/ML INJ (NOV) INSULIN REGULAR INSULIN REGULAR NOVOLIN-R 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 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
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