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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 51311 XALACOM 0.005% /0.5% EYE DR (PFI/STO) LATANOP LATANOPROST|TIMOLOL XALACOM 2.5ML C 28.68 28.68 EYE DROP 0 BOTT PFI PFIZER CORPORATION STO BRYDEN STOKES LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 51311 XALACOM 0.005% /0.5% EYE DR (PFI/STO) LATANOP LATANOPROST|TIMOLOL XALACOM 2.5ML C 37.89 37.89 EYE DROP 0 BOTT PFI PFIZER CORPORATION STO BRYDEN STOKES LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-07-27 2024-03-31 Price Change OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS 2022-07-26
41 51311 XALACOM 0.005%|0.5% EYE DR (PFI) LATANOPROST|TIMOLOL (C) LATANOPROST|TIMOLOL XALACOM 2.5ML C 34.58 34.5771 BOTT 1 BOTT PFI PFIZER CORPORATION STO BRYDEN STOKES LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2024-04-01 2026-03-31 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
40 51313 LOUTEN T 0.005% | 0.5% EYE DR (LPO/COL) LATANOP LATANOPROST|TIMOLOL LOUTEN T 2.5ML A 13.05 13.05 EYE DROP 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 51313 LOUTEN T 0.005%|0.5% EYE DR (LPO) LATANO LATANOPROST|TIMOLOL LOUTEN T 2.5ML A 14.35 14.3528 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2024-04-01 2026-03-31 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
42 51313 LOUTEN T 0.005%|0.5% EYE DR (LPO) LATANOPROST|TIMOLOL LATANOPROST|TIMOLOL LOUTEN T 2.5ML C 17.67 17.67 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL AVENTA BARBADOS B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2026-04-01 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
40 51316 XALACOM 0.005% /0.5% EYE DR (PFI/SBI) LATANOP LATANOPROST|TIMOLOL XALACOM 2.5ML C 37.90 37.90 EYE DROP 0 BOTT PFI PFIZER CORPORATION SBI MASSY DISTRIBUTION (BDOS) LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 Price Change OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS 2022-05-05
41 51316 XALACOM 0.005%|0.5% EYE DR (PFI) LATANOPROST|TIMOLOL (C) LATANOPROST|TIMOLOL XALACOM 2.5ML C 34.58 34.5771 BOTT 1 BOTT PFI PFIZER CORPORATION SBI MASSY DISTRIBUTION (BDOS) LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2024-04-01 2026-03-31 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
42 5131BL LATANOPROST|TIMOLOL EYE DR (MTP) LATANOPROST|TIMOLOL LATANOPROST|TIMOLOL 2.5ML A 8.86 8.86 BOTT 1 BOTT MTP MARTINDALE PHARMACEUTICALS AHI ARMSTRONG HEALTHCARE INC B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2026-04-01 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
42 5131Q XALACOM 0.005%|0.5% EYE DR (PFI) LATANOPROST|TIMOLOL LATANOPROST|TIMOLOL XALACOM 2.5ML C 34.58 34.58 BOTT 1 BOTT PFI PFIZER CORPORATION COL AVENTA BARBADOS B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2026-04-01 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
40 A5311 XALATAN 0.005% EYE DR (PFI/STO) LATANOPROST LATANOPROST XALATAN 2.5ML A 11.66 11.66 EYE DROP 1 BOTT PFI PFIZER CORPORATION STO BRYDEN STOKES LTD B 524028 EENT PROSTAGLANDIN ANALOGS 2022-04-01 2024-03-31 Price Change OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS 2022-05-03
40 A531AH LOUTEN EMULSION 0.005% EYE DR (LPO/COL) LATAN LATANOPROST LOUTEN EMULSION 2.5ML A 9.08 9.08 EYE DROP 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD B 524028 EENT PROSTAGLANDIN ANALOGS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS 2022-02-18
41 A531AH LOUTEN EMULSION 0.005% EYE DR (LPO) LATA LATANOPROST LOUTEN EMULSION 2.5ML A 9.08 9.0792 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD B 524028 EENT PROSTAGLANDIN ANALOGS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT PROSTAGLANDIN ANALOGS
42 A531AH LOUTEN EMULSION 0.005% EYE DR (LPO) LATA LATANOPROST LOUTEN EMULSION 2.5ML C 16.31 16.31 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL AVENTA BARBADOS B 524028 EENT PROSTAGLANDIN ANALOGS 2026-04-01 OPHTHALMIC 6 EENT PROSTAGLANDIN ANALOGS
41 A531BF XALATAN 0.005% EYE DR (PFI) LATANOPROST LATANOPROST XALATAN 2.5ML A 8.86 8.8617 BOTT 2 BOTT PFI PFIZER CORPORATION COL COLLINS LIMITED B 524028 EENT PROSTAGLANDIN ANALOGS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT PROSTAGLANDIN ANALOGS 2025-04-01
42 A531BF XALATAN 0.005% EYE DR (PFI) LATANOPROST LATANOPROST XALATAN 2.5ML A 8.51 8.51 BOTT 1 BOTT PFI PFIZER CORPORATION COL AVENTA BARBADOS B 524028 EENT PROSTAGLANDIN ANALOGS 2026-04-01 OPHTHALMIC 6 EENT PROSTAGLANDIN ANALOGS
40 A531H XALATAN 0.005% EYE DR (PFI/SBI) LATANOPROST LATANOPROST XALATAN 2.5ML A 11.66 11.66 EYE DROP 1 BOTT PFI PFIZER CORPORATION SBI MASSY DISTRIBUTION (BDOS) LTD B 524028 EENT PROSTAGLANDIN ANALOGS 2022-04-01 2024-03-31 Price Change OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS 2022-05-03
41 A531H XALATAN 0.005% EYE DR (PFI) LATANOPROST LATANOPROST XALATAN 2.5ML A 8.86 8.8617 BOTT 1 BOTT PFI PFIZER CORPORATION SBI MASSY DISTRIBUTION (BDOS) LTD B 524028 EENT PROSTAGLANDIN ANALOGS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT PROSTAGLANDIN ANALOGS