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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 36613 LIPOFUNDIN 20% INJ (BRA/COL) SOYA BEAN OIL SOYA BEAN OIL LIPOFUNDIN 500ML BQ 34.39 34.39 INJECTION 0 BOTT BRA B. BRAUN MELSUNGEN AG CARL-BRAUN-STRABE COL COLLINS LTD 4020 CALORIC AGENTS 2022-04-01 2024-03-31 IV 0 ELECTROLYTIC, CALORIC, AND WATER BALANCE
41 36613 LIPOFUNDIN 20% INJ (BRA) SOYA BEAN OIL SOYA BEAN OIL LIPOFUNDIN 500ML BQ 41.26 41.2642 BOTT 0 BOTT BRA B. BRAUN MELSUNGEN AG CARL-BRAUN-STRABE COL COLLINS LTD 4020 CALORIC AGENTS 2024-04-01 2026-03-31 IV 0 CALORIC AGENTS
42 36613 LIPOFUNDIN 20% INJ (BRA) SOYA BEAN OIL SOYA BEAN OIL LIPOFUNDIN 500ML BQ 65.24 65.24 BOTT 0 BOTT BRA B. BRAUN MELSUNGEN AG CARL-BRAUN-STRABE COL AVENTA BARBADOS 4020 CALORIC AGENTS 2026-04-01 IV 0 CALORIC AGENTS