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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 3582B SODIUM BICARBONATE 8.4% INJ (BRA/COL) SODIUM BICARBONATE SODIUM BICARBONATE 100ML B 6.50 6.50 INJECTION 0 VIAL BRA B. BRAUN MELSUNGEN AG CARL-BRAUN-STRABE COL COLLINS LTD 4008 ALKALINIZING AGENTS 2022-04-01 2024-03-31 IV 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE
41 3582B SODIUM BICARBONATE 8.4% INJ (BRA) (B) SODIUM BICARBONATE SODIUM BICARBONATE 100ML B 6.96 6.9589 VIAL 70 VIAL BRA B. BRAUN MELSUNGEN AG CARL-BRAUN-STRABE COL COLLINS LTD 4008 ALKALINIZING AGENTS 2024-04-01 2026-03-31 IV 0 ALKALINIZING AGENTS
42 3582B SODIUM BICARBONATE 8.4% INJ (BRA) SODIUM BICARBONATE SODIUM BICARBONATE 100ML B 9.51 9.51 VIAL 70 VIAL BRA B. BRAUN MELSUNGEN AG CARL-BRAUN-STRABE COL AVENTA BARBADOS 4008 ALKALINIZING AGENTS 2026-04-01 IV 0 ALKALINIZING AGENTS
41 3582F SODIUM BICARBONATE 8.4% INJ (KWA) (B) SODIUM BICARBONATE SODIUM BICARBONATE 50ML B 4.4 4.4037 VIAL 70 VIAL KWA KWALITY PHARMACEUTICALS ATB ANSA TRADING BARBADOS LTD 4008 ALKALINIZING AGENTS 2024-04-01 2026-03-31 IV 0 ALKALINIZING AGENTS
42 3582G SODIUM BICARBONATE 8.4% INJ (KWA) SODIUM BICARBONATE SODIUM BICARBONATE 50ML B 5.03 5.03 VIAL 70 KWA KWALITY PHARMACEUTICALS STO BRYDEN STOKES LTD 4008 ALKALINIZING AGENTS 2026-04-01 Add to Contract as Cat B IV 0 ALKALINIZING AGENTS 2026-03-02
40 35831 SODIUM BICARBONATE 8.4% INJ (FSB/ATB) SODIUM BICARBONATE SODIUM BICARBONATE 10ML B 1.14 1.14 INJECTION 0 VIAL FSB FLAGSHIP BIOTECH ATB ANSA TRADING BARBADOS LTD 4008 ALKALINIZING AGENTS 2022-04-01 2024-03-31 IV 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE
41 35831 SODIUM BICARBONATE 8.4% INJ (FSB) SODIUM BICARBONATE SODIUM BICARBONATE 10ML B 1.2 1.1961 VIAL 70 VIAL FSB FLAGSHIP BIOTECH ATB ANSA TRADING BARBADOS LTD 4008 ALKALINIZING AGENTS 2024-04-01 2026-03-31 IV 0 ALKALINIZING AGENTS
42 35833 SODIUM BICARBONATE 8.4% INJ (FSB) SODIUM BICARBONATE SODIUM BICARBONATE 10ML B 1.09 1.09 VIAL 70 FSB FLAGSHIP BIOTECH STO BRYDEN STOKES LTD 4008 ALKALINIZING AGENTS 2026-04-01 Add to Contract as Cat B IV 0 ALKALINIZING AGENTS 2026-03-05
42 35861 SODIUM BICARBONATE 4.2% INJ (MTP) SODIUM BICARBONATE SODIUM BICARBONATE 10X10ML B 103.35 10.34 AMPG 0 AMP MTP MARTINDALE PHARMACEUTICALS AHI ARMSTRONG HEALTHCARE INC 4008 ALKALINIZING AGENTS 2026-04-01 IV 0 ALKALINIZING AGENTS
40 68911 E-Z-GAS II (EZM/COL) SOD BIC/CIT ACID/SIMET CITRIC ACID|SIMETHICONE|SODIUM BICARBONATE E-Z-GAS II 50X4G BQ 462.12 9.24 0 SACH EZM E-Z-EM INC. COL COLLINS LTD 3668 ROENTGENOGRAPHY 2022-04-01 2024-03-31 Oral 0 DIAGNOSTIC AGENTS
41 68911 E-Z-GAS II (EZM) SOD BIC/CIT ACID/SIME (BQ) CITRIC ACID|SIMETHICONE|SODIUM BICARBONATE E-Z-GAS II 50X4G BQ 508.33 10.1665 SACH 0 BOX EZM E-Z-EM INC. COL COLLINS LTD 3668 ROENTGENOGRAPHY 2024-04-01 2026-03-31 ORAL 0 ROENTGENOGRAPHY
42 68911 E-Z-GAS II (EZM) SOD BIC/CIT ACID/SIME CITRIC ACID|SIMETHICONE|SODIUM BICARBONATE E-Z-GAS II 50X4G BQ 532.79 10.66 SACH 0 BOX EZM E-Z-EM INC. COL AVENTA BARBADOS 3668 ROENTGENOGRAPHY 2026-04-01 ORAL 0 ROENTGENOGRAPHY