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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 4331AN XELJANZ 5MG TAB (PFI/STO) TOFACITINIB TOFACITINIB XELJANZ 60'S C 2,373.42 39.56 TABLET 0 TAB PFI PFIZER CORPORATION STO BRYDEN STOKES LTD 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 Oral 0 ANTINEOPLASTICS
41 4331AN XELJANZ 5MG TAB (PFI) TOFACITINIB (C) TOFACITINIB XELJANZ 60'S C 2373.42 39.5571 TAB 0 BOX PFI PFIZER CORPORATION STO BRYDEN STOKES LTD 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 ORAL 0 ANTINEOPLASTICS