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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 01027 NYSTATIN 100,000U/ML SUSP (HEA/RXP) NYSTATIN NYSTATIN 60ML A 5.71 0.10 SUSPENSION 180 ML HEA HEALTH 2000 INC RXP RX PRO INC 081428 POLYENES 2022-04-01 2024-03-31 Oral 0 ANTI-INFECTIVE AGENTS
42 0102AA NYSTATIN 100,000U/ML SUSP (HEA) NYSTATIN NYSTATIN 60ML A 5.65 0.09 ML 180 BOTT HEA HEALTH 2000 INC CWS CAPSULE WHOLESALE 081428 POLYENES 2026-04-01 Add to Contract as Cat A ORAL 0 POLYENES 2026-01-26
42 0102AB NYSTATIN 100,000U/ML SUSP (FSB) NYSTATIN NYSTATIN 60ML A 5.14 0.09 ML 180 FSB FLAGSHIP BIOTECH STO BRYDEN STOKES LTD 081428 POLYENES 2026-04-01 Add to Contract as Cat A ORAL 0 POLYENES 2026-03-05
42 0102AC NYSTATIN 100,000U/ML SUSP (HEA) NYSTATIN NYSTATIN 60ML A 5.65 0.09 ML 180 BOTT HEA HEALTH 2000 INC STO BRYDEN STOKES LTD 081428 POLYENES 2026-04-01 Add to Contract as Cat A ORAL 0 POLYENES 2026-02-26
40 0102T PMS-NYSTATIN 100,000U/ML SUSP (PMS/COL) NYSTATIN PMS-NYSTATIN 100ML A 6.80 0.07 SUSPENSION 180 ML PMS PHARMASCIENCE COL COLLINS LTD 081428 POLYENES 2022-04-01 2024-03-31 Oral 0 ANTI-INFECTIVE AGENTS
41 0102T PMS-NYSTATIN 100,000U/ML SUSP (PMS) NYSTATIN PMS-NYSTATIN 100ML A 8.15 0.0816 ML 180 BOTT PMS PHARMASCIENCE COL COLLINS LTD 081428 POLYENES 2024-04-01 2026-03-31 ORAL 0 POLYENES
40 0102V NYSTATIN 100,000U/ML SUSP (HEA/ATB) NYSTATIN NYSTATIN 60ML A 5.71 0.0952 SUSPENSION HEA HEALTH 2000 INC ATB ANSA TRADING BARBADOS LTD 81428 POLYENES 2022-12-07 2024-03-31 Change Local Agent ORAL 0 POLYENES 2022-11-25
41 0102V NYSTATIN 100,000U/ML SUSP (HEA) NYSTATIN NYSTATIN 60ML A 5.76 0.096 ML 180 BOTT HEA HEALTH 2000 INC ATB ANSA TRADING BARBADOS LTD 081428 POLYENES 2024-04-01 2026-03-31 ORAL 0 POLYENES
42 0102Z NYSTATIN 100,000U/ML SUSP (HEA) NYSTATIN NYSTATIN 60ML A 5.65 0.09 ML 180 BOTT HEA HEALTH 2000 INC AHI ARMSTRONG HEALTHCARE INC 081428 POLYENES 2026-04-01 Price Change ORAL 0 POLYENES 2025-10-31