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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 A0422 MYFORTIC 180MG CAP (NVS/COL) MYCOPHENOLIC ACI MYCOPHENOLIC ACID MYFORTIC 120'S C 320.76 2.67 CAPSULE 0 CAP NVS NOVARTIS CARIBE SA COL COLLINS LTD 9244 IMMUNOSUPPRESSIVE AGENTS 2022-04-01 2024-03-31 Oral 0 UNCLASSIFIED THERAPEUTIC AGENTS
41 A0422 MYFORTIC 180MG CAP (NVS) MYCOPHENOLIC AC (C) MYCOPHENOLIC ACID MYFORTIC 120'S C 320.76 2.673 CAP 240 BOX NVS NOVARTIS CARIBE SA COL COLLINS LTD 9244 IMMUNOSUPPRESSIVE AGENTS 2024-04-01 2026-03-31 ORAL 6 IMMUNOSUPPRESSIVE AGENTS