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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
41 4181BL PHESGO 60MG/ML|60MG/ML INJ (ROC) PERTUZUMAB|TRASTUZUMAB (C) PERTUZUMAB|TRASTUZUMAB PHESGO 10ML C 12626.62 12626.62 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 9244 IMMUNOSUPPRESSIVE AGENTS 2024-04-01 2026-03-31 SC 0 IMMUNOSUPPRESSIVE AGENTS
41 4181BW PHESGO 1200MG|600MG INJ (ROC) PERTUZUMAB|TRASTUZUMAB (C) PERTUZUMAB|TRASTUZUMAB PHESGO 15ML VIAL C 21270.89 21270.885 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 SC 0 ANTINEOPLASTICS
40 4181G HERCEPTIN 600MG SC INJ (ROC/AHI) TRASTUZUMAB TRASTUZUMAB HERCEPTIN 5ML VIAL C 3,982.34 3,982.34 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 SC 0 ANTINEOPLASTICS
41 4181G HERCEPTIN 600MG SC INJ (ROC) TRASTUZUMAB (C) TRASTUZUMAB HERCEPTIN 5ML VIAL C 3982.34 3982.3447 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 SC 0 ANTINEOPLASTICS
40 4181T KADCYLA 100MG/ML INJ (ROC/AHI) ADO-TRASTUZUMAB EMTANSINE ADO-TRASTUZUMAB EMTANSINE KADCYLA 15ML C 5,844.40 5,844.40 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181T KADCYLA 100MG/ML INJ (ROC) ADO-TRASTUZUMAB EMTANSINE (C) ADO-TRASTUZUMAB EMTANSINE KADCYLA 15ML C 5844.4 5844.3966 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
40 4181U KADCYLA 160MG/ML INJ (ROC/AHI) ADO-TRASTUZUMAB EMTANSINE ADO-TRASTUZUMAB EMTANSINE KADCYLA 20ML C 9,351.03 9,351.03 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181U KADCYLA 160MG/ML INJ (ROC) ADO-TRASTUZUMAB EMTANSINE (C) ADO-TRASTUZUMAB EMTANSINE KADCYLA 20ML C 9351.03 9351.0346 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS