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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 4181C ACTEMRA 20MG/ML INJ (ROC/AHI) TOCILIZUMAB TOCILIZUMAB ACTEMRA 10ML VIAL C 706.76 706.76 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181C ACTEMRA 20MG/ML INJ (ROC) TOCILIZUMAB (C) TOCILIZUMAB ACTEMRA 10ML VIAL C 706.76 706.7642 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 9236 DISEASE MODIFYING ANTIRHEUMATIC AGENTS 2024-04-01 2026-03-31 IV 0 DISEASE MODIFYING ANTIRHEUMATIC AGENTS
40 4181D ACTEMRA 20MG/ML INJ (ROC/AHI) TOCILIZUMAB TOCILIZUMAB ACTEMRA 4ML VIAL C 282.71 282.71 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181D ACTEMRA 20MG/ML INJ (ROC) TOCILIZUMAB (C) TOCILIZUMAB ACTEMRA 4ML VIAL C 282.71 282.7057 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 9236 DISEASE MODIFYING ANTIRHEUMATIC AGENTS 2024-04-01 2026-03-31 IV 0 DISEASE MODIFYING ANTIRHEUMATIC AGENTS
40 4181J ACTEMRA 162MG/0.9ML INJ (ROC/AHI) TOCILIZUMAB TOCILIZUMAB ACTEMRA 4X0.9ML C 706.76 176.69 INJECTION 0 AMP ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181J ACTEMRA 162MG/0.9ML INJ (ROC) TOCILIZUMA (C) TOCILIZUMAB ACTEMRA 4X0.9ML C 1698.95 424.7381 AMP 0 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 9236 DISEASE MODIFYING ANTIRHEUMATIC AGENTS 2024-04-01 2026-03-31 IV 0 DISEASE MODIFYING ANTIRHEUMATIC AGENTS