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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 4181W OCREVUS 300MG INJ (ROC/AHI) OCRELIZUMAB OCRELIZUMAB OCREVUS 10ML C 17,533.1 17,533.1 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181W OCREVUS 300MG INJ (ROC) OCRELIZUMAB (BQ) OCRELIZUMAB OCREVUS 10ML BQ 17533.19 17533.189 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 9220 BIOLOGIC RESPONSE MODIFIER 2024-04-01 2026-03-31 IV 0 BIOLOGIC RESPONSE MODIFIER