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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 0111FB BACTERAM 500MG TAB (MBL) CEFADROXIL CEFADROXIL BACTERAM 12'S A 5.11 0.4259 TAB 28 BOX MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC 08120604 FIRST GEN CEPHALOSPORINS 2024-04-01 2026-03-31 ORAL 0 FIRST GEN CEPHALOSPORINS
41 0112CK CEFADROXIL 50MG/ML SUSP (MBL) CEFADROXIL CEFADROXIL 60ML A 7.96 0.1327 ML 120 BOTT MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC 08120604 FIRST GEN CEPHALOSPORINS 2024-04-01 2026-03-31 ORAL 0 FIRST GEN CEPHALOSPORINS
41 0131DN AZICURE 40MG/ML SUSP (MBL) AZITHROM AZITHROMYCIN AZICURE 30ML A 9.24 0.3081 ML 30 BOTT MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC 08121204 ERYTHROMYCINS 2024-04-01 2026-03-31 ORAL 0 ERYTHROMYCINS
41 0141GH ERYTHROMYCIN 250MG TAB (MBL) ERYTHROMYCIN BASE ERYTHROMYCIN 100'S A 32.54 0.3254 TAB 56 BOX MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC 08121292 OTHER MACROLIDES 2024-04-01 2026-03-31 ORAL 0 OTHER MACROLIDES
40 07229 AVEXA 30MG TAB (MBL/AHI) DEFLAZACORT DEFLAZACORT AVEXA 1X10 C 29.00 2.90 TABLET 0 TAB MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC 6804 ADRENALS 2022-04-01 2024-03-31 Add to Contract as Cat C oral 0 HORMONES AND SYNTHETIC SUBSTITUTES 2022-03-10
40 0981AT FERROUS FUMARATE 200MG TAB (MBL/AHI) FERROUS FUMARATE FERROUS FUMARATE 100'S A 4.89 0.05 TABLET 90 TAB MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC 200404 IRON PREPARATIONS 2022-04-01 2022-09-30 Oral 6 BLOOD FORMATION, COAGULATION AND THROMBOSIS 2022-03-29
40 1101H PROPRANOLOL 10MG TAB (MBL/AHI) PROPRANOLOL PROPRANOLOL 30'S A 1.22 0.04 TABLET 90 TAB MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC B 2424 BETA ADRENERGIC BLOCKING AGENTS 2022-04-01 2024-03-31 Oral 6 CARDIOVASCULAR DRUGS
41 1101H PROPRANOLOL 10MG TAB (MBL) PROPRANOLOL PROPRANOLOL 30'S A 1.25 0.0417 TAB 90 BOX MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC B 2424 BETA ADRENERGIC BLOCKING AGENTS 2024-04-01 2026-03-31 ORAL 6 BETA ADRENERGIC BLOCKING AGENTS
40 1102Z PROPRANOLOL 40MG TAB (MBL/AHI) PROPRANOLOL PROPRANOLOL 30'S A 1.33 0.04 TABLET 180 TAB MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC B 2424 BETA ADRENERGIC BLOCKING AGENTS 2022-04-01 2024-03-31 Oral 6 CARDIOVASCULAR DRUGS
41 1102Z PROPRANOLOL 40MG TAB (MBL) PROPRANOLOL PROPRANOLOL 30'S A 1.41 0.0471 TAB 180 BOX MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC B 2424 BETA ADRENERGIC BLOCKING AGENTS 2024-04-01 2026-03-31 ORAL 6 BETA ADRENERGIC BLOCKING AGENTS
42 1102Z PROPRANOLOL 40MG TAB (MBL) PROPRANOLOL PROPRANOLOL 30'S A 2.04 0.07 TAB 180 BLIS MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC B 2424 BETA ADRENERGIC BLOCKING AGENTS 2026-04-01 ORAL 6 BETA ADRENERGIC BLOCKING AGENTS
40 20931 CHLORTHALIDONE 12.5MG TAB (MBL/AHI) CHLORTHALIDONE CHLORTHALIDONE 30'S A 5.46 0.18 TABLET 30 TAB MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC B 402824 THIAZIDE LIKE DIURETICS 2022-04-01 2024-03-31 Oral 6 ELECTROLYTIC, CALORIC, AND WATER BALANCE
41 2663B DARDEX 4MG TAB (MBL) DEXAMETHASONE DEXAMETHASONE DARDEX 30'S A 6.33 0.2111 TAB 90 BOX MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC 6804 ADRENALS 2024-04-01 2026-03-31 ORAL 6 ADRENALS
40 2713E PREDNISOLONE 20MG TAB (MBL/AHI) PREDNISOLONE PREDNISOLONE 100'S A 17.29 0.1729 TABLET IMMED 90 MBL MEDICAMEN BIOTECH LTD AHI ARMSTRONG HEALTHCARE INC 6804 ADRENALS 2023-03-20 2024-03-31 Add to Contract as Cat A Oral 6 ADRENALS 2023-01-20