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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 B1513 XARELTO 10MG TAB (BSP/AHI) RIVAROXABAN RIVAROXABAN XARELTO 10'S C 60.54 6.05 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1513 XARELTO 10MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 10'S C 60.54 6.0537 TAB 30 BOX BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
40 B1514 XARELTO 10MG TAB (BSP/COL) RIVAROXABAN RIVAROXABAN XARELTO 10'S C 60.54 6.05 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1514 XARELTO 10MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 10'S C 60.54 6.0537 TAB 30 BOX BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
41 B1517 XARELTO 2.5MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 28'S C 84.81 3.0289 TAB 60 BOX BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
40 B151A XARELTO 2.5MG TAB (BSP/AHI) RIVAROXABAN RIVAROXABAN XARELTO 56'S C 169.62 3.03 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B151A XARELTO 2.5MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 56'S C 169.62 3.029 TAB 60 BOX BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
40 B151C XARELTO 2.5MG TAB (BSP/AHI) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 84.81 3.03 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B151C XARELTO 2.5MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 28'S C 84.81 3.029 TAB 60 BOX BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 6 DIRECT THROMBIN INHIBITORS
40 B1523 XARELTO 15MG TAB (BSP/AHI) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 169.92 6.07 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1523 XARELTO 15MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 28'S C 169.92 6.0687 TAB 30 BOX BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
40 B1525 XARELTO 15MG TAB (BSP/COL) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 169.92 6.07 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1525 XARELTO 15MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 28'S C 169.92 6.0687 TAB 30 BOX BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
40 B1527 XARELTO 15MG TAB (BSP/AHI) RIVAROXABAN RIVAROXABAN XARELTO 14'S C 84.97 6.07 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1527 XARELTO 15MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 14'S C 84.97 6.0696 TAB 30 BOX BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
40 B1528 XARELTO 15MG TAB (BSP/COL) RIVAROXABAN RIVAROXABAN XARELTO 14'S C 84.97 6.07 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1528 XARELTO 15MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 14'S C 84.97 6.0696 TAB 30 BOX BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
40 B1533 XARELTO 20MG TAB (BSP/AHI) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 169.92 6.07 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 B1533 XARELTO 20MG TAB (BSP) RIVAROXABAN (C) RIVAROXABAN XARELTO 28'S C 169.92 6.0687 TAB 30 BOX BSP BAYER SCHERING PHARMA AG. AHI ARMSTRONG HEALTHCARE INC 20120412 DIRECT THROMBIN INHIBITORS 2024-04-01 2026-03-31 ORAL 0 DIRECT THROMBIN INHIBITORS
40 B1534 XARELTO 20MG TAB (BSP/COL) RIVAROXABAN RIVAROXABAN XARELTO 28'S C 169.92 6.07 TABLET 0 TAB BSP BAYER SCHERING PHARMA AG. COL COLLINS LTD 20120412 DIRECT THROMBIN INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS