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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 55511 THALIDOMIDE 50MG CAP (DIL/AHI) THALIDOMIDE THALIDOMIDE 30'S C 62.25 2.08 CAPSULE 0 CAP DIL FRESENIUS KABI AHI ARMSTRONG HEALTHCARE INC 9220 BIOLOGIC RESPONSE MODIFIER 2022-04-01 2024-03-31 Oral 0 UNCLASSIFIED THERAPEUTIC AGENTS
42 55511 THALIDOMIDE 50MG CAP (DIL) THALIDOMIDE THALIDOMIDE 30'S C 48.11 1.60 CAP 0 BLIS DIL FRESENIUS KABI AHI ARMSTRONG HEALTHCARE INC 9220 BIOLOGIC RESPONSE MODIFIER 2026-04-01 ORAL 0 BIOLOGIC RESPONSE MODIFIER
40 55521 THALIDOMIDE 100MG CAP (DIL/AHI) THALIDOMIDE THALIDOMIDE 30'S C 110.50 3.68 CAPSULE 0 CAP DIL FRESENIUS KABI AHI ARMSTRONG HEALTHCARE INC 9220 BIOLOGIC RESPONSE MODIFIER 2022-04-01 2024-03-31 Oral 0 UNCLASSIFIED THERAPEUTIC AGENTS
42 55521 THALIX 100MG CAP (DIL) THALIDOMIDE THALIDOMIDE THALIX 30'S C 60.18 2.01 CAP 0 BLIS DIL FRESENIUS KABI AHI ARMSTRONG HEALTHCARE INC 9220 BIOLOGIC RESPONSE MODIFIER 2026-04-01 ORAL 0 BIOLOGIC RESPONSE MODIFIER
40 5552D THALIDOMIDE 100MG CAP (SLS/AHI) THALIDOMIDE THALIDOMIDE 30'S C 93.78 3.13 CAPSULE 0 CAP SLS SAMARTH LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 9220 BIOLOGIC RESPONSE MODIFIER 2022-04-01 2024-03-31 Add to Contract as Cat C Oral 0 UNCLASSIFIED THERAPEUTIC AGENTS 2021-12-16
41 5552D THALIDOMIDE 100MG CAP (SLS) THALIDOMIDE THALIDOMIDE 30'S C 63.5 2.1167 CAP 0 BOX SLS SAMARTH LIFE SCIENCES AHI ARMSTRONG HEALTHCARE INC 9220 BIOLOGIC RESPONSE MODIFIER 2024-04-01 2026-03-31 ORAL 0 BIOLOGIC RESPONSE MODIFIER