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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 52424 TRIVASTAL RETARD 50MG TAB (SER/STO) PIRIBEDIL PIRIBEDIL TRIVASTAL RETARD 30'S C 23.46 0.78 TABLET 0 TAB SER LES LABORATOIRES SERVIER STO BRYDEN STOKES LTD 9300 VASOACTIVE DRUGS 2022-04-01 2024-03-31 Oral 0 VASOACTIVE DRUGS
41 52424 TRIVASTAL RETARD 50MG TAB (SER) PIRIBEDIL (C) PIRIBEDIL TRIVASTAL RETARD 30'S C 26.34 0.878 TAB 30 BOX SER LES LABORATOIRES SERVIER STO BRYDEN STOKES LTD 9300 VASOACTIVE DRUGS 2024-04-01 2026-03-31 ORAL 60 VASOACTIVE DRUGS
40 5242H TRIVASTAL RETARD 50MG TAB (SER/COL) PIRIBEDIL PIRIBEDIL TRIVASTAL RETARD 30'S C 23.46 0.78 TABLET 0 TAB SER LES LABORATOIRES SERVIER COL COLLINS LTD 1216 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS 2022-04-01 2024-03-31 Oral 0 AUTONOMIC DRUGS
41 5242H TRIVASTAL RETARD 50MG TAB (SER) PIRIBEDIL (C) PIRIBEDIL TRIVASTAL RETARD 30'S C 26.34 0.878 TAB 30 BOX SER LES LABORATOIRES SERVIER COL COLLINS LTD 1216 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS 2024-04-01 2026-03-31 ORAL 60 SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS