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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 B4911 XOLAIR 150MG INJ (NVS/COL) OMALIZUMAB OMALIZUMAB XOLAIR 150MG VIAL C 1,304.93 1,304.93 INJECTION 0 VIAL NVS NOVARTIS CARIBE SA COL COLLINS LTD 4810 RESPIRATORY INFLAMMATORY AGENTS 2022-04-01 2024-03-31 IV 0 RESPIRATORY TRACT AGENTS
41 B4911 XOLAIR 150MG INJ (NVS) OMALIZUMAB (C) OMALIZUMAB XOLAIR 150MG VIAL C 1304.93 1304.9314 VIAL 0 VIAL NVS NOVARTIS CARIBE SA COL COLLINS LTD 4810 RESPIRATORY INFLAMMATORY AGENTS 2024-04-01 2026-03-31 IV 0 RESPIRATORY INFLAMMATORY AGENTS
42 B4911 XOLAIR 150MG INJ (NVS) OMALIZUMAB OMALIZUMAB XOLAIR 150MG VIAL C 1,304.93 1,304.93 VIAL 0 VIAL NVS NOVARTIS CARIBE SA COL AVENTA BARBADOS 4810 RESPIRATORY INFLAMMATORY AGENTS 2026-04-01 IV 0 RESPIRATORY INFLAMMATORY AGENTS
40 B4913 OMALIREL 150MG INJ (RLS/AHI) OMALIZUMAB OMALIZUMAB OMALIREL 150MG VIAL C 844.86 844.86 INJECTION 0 VIAL RLS RELIANCE LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 4810 RESPIRATORY INFLAMMATORY AGENTS 2022-04-01 2024-03-31 IV 0 RESPIRATORY TRACT AGENTS
41 B4913 OMALIREL 150MG INJ (RLS) OMALIZUMAB (C) OMALIZUMAB OMALIREL 150MG VIAL C 844.86 844.8551 VIAL 0 VIAL RLS RELIANCE LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 4810 RESPIRATORY INFLAMMATORY AGENTS 2024-04-01 2026-03-31 IV 0 RESPIRATORY INFLAMMATORY AGENTS
42 B4913 OMALIREL 150MG INJ (RLS) OMALIZUMAB OMALIZUMAB OMALIREL 150MG VIAL BQ 747.54 747.54 VIAL 0 VIAL RLS RELIANCE LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 4810 RESPIRATORY INFLAMMATORY AGENTS 2026-04-01 IV 0 RESPIRATORY INFLAMMATORY AGENTS