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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
41 4181BL PHESGO 60MG/ML|60MG/ML INJ (ROC) PERTUZUMAB|TRASTUZUMAB (C) PERTUZUMAB|TRASTUZUMAB PHESGO 10ML C 12626.62 12626.62 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 9244 IMMUNOSUPPRESSIVE AGENTS 2024-04-01 2026-03-31 SC 0 IMMUNOSUPPRESSIVE AGENTS
41 4181BW PHESGO 1200MG|600MG INJ (ROC) PERTUZUMAB|TRASTUZUMAB (C) PERTUZUMAB|TRASTUZUMAB PHESGO 15ML VIAL C 21270.89 21270.885 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 SC 0 ANTINEOPLASTICS
41 4181K PERJETA 420MG INJ (ROC) PERTUZUMAB (C) PERTUZUMAB PERJETA 14ML C 8644.27 8644.2703 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS