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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 3921CH BRILINTA 90MG TAB (AZN/COL) TICAGRELOR TICAGRELOR BRILINTA 60'S C 122.32 2.04 TABLET 0 TAB AZN ASTRAZENECA AB COL COLLINS LTD 201218 PLATELET AGGREGATION INHIBITORS 2022-04-01 2024-03-31 Oral 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 3921CH BRILINTA 90MG TAB (AZN) TICAGRELOR (C) TICAGRELOR BRILINTA 60'S C 122.32 2.0387 TAB 60 BOX AZN ASTRAZENECA AB COL COLLINS LTD 201218 PLATELET AGGREGATION INHIBITORS 2024-04-01 2026-03-31 ORAL 0 PLATELET AGGREGATION INHIBITORS