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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 72017 METALYSE 50MG INJ (BOE/STO) TENECTEPLASE TENECTEPLASE METALYSE 50MG VIAL BQ 2,535.76 2,535.76 INJECTION 0 VIAL BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 201220 THROMBOLYTIC AGENTS 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 72017 METALYSE 50MG INJ (BOE) TENECTEPLASE (BQ) TENECTEPLASE METALYSE 50MG VIAL BQ 2873 2872.9966 VIAL 0 VIAL BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 201220 THROMBOLYTIC AGENTS 2024-04-01 2026-03-31 IV 0 THROMBOLYTIC AGENTS