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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 37419 OSMITROL 10% INJ (BAX/STO) MANNITOL MANNITOL OSMITROL 500ML B 12.75 12.75 INJECTION 0 BOTT BAX BAXTER EXPORT CORP. STO BRYDEN STOKES LTD 402812 OSMOTIC DIURETICS 2022-04-01 2024-03-31 Add to Contract as Cat B IV 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE 2022-04-01
41 37419 OSMITROL 10% INJ (BAX) MANNITOL MANNITOL OSMITROL 500ML BQ 14.57 14.5702 BAG 0 BAG BAX BAXTER EXPORT CORP. STO BRYDEN STOKES LTD 402812 OSMOTIC DIURETICS 2024-04-01 2026-03-31 IV 0 OSMOTIC DIURETICS
40 3742E OSMITROL (2D5632Q) 20% INJ (BAX/STO) MANNITOL MANNITOL OSMITROL (2D5632Q) 250ML BQ 13.86 13.86 INJECTION 0 BOTT BAX BAXTER EXPORT CORP. STO BRYDEN STOKES LTD 402812 OSMOTIC DIURETICS 2022-04-01 2024-03-31 IV 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE
41 3742E OSMITROL (2D5632Q) 20% INJ (BAX) MANNITOL MANNITOL OSMITROL (2D5632Q) 250ML BQ 19.98 19.9797 BAG 0 BAG BAX BAXTER EXPORT CORP. STO BRYDEN STOKES LTD 402812 OSMOTIC DIURETICS 2024-04-01 2026-03-31 IV 0 OSMOTIC DIURETICS
42 3742E OSMITROL (2D5632Q) 20% INJ (BAX) MANNITOL MANNITOL OSMITROL (2D5632Q) 250ML BQ 22.51 22.51 BAG 0 BAG BAX BAXTER EXPORT CORP. STO BRYDEN STOKES LTD 402812 OSMOTIC DIURETICS 2026-04-01 IV 0 OSMOTIC DIURETICS