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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 3701BA ACCU-CHEK INSTANT GLUC (PRI/STO) DIAGNOSTIC DIAGNOSTIC BLOOD GLUCOSE ACCU-CHEK INSTANT 50'S A 42.30 42.30 GLUCOSE STRI 1 PACK PRI PRODUCTOS ROCHE INTERAMERICANA SA STO BRYDEN STOKES LTD B 3626 DIABETES MELLITUS 2022-04-01 2024-03-31 6 DIAGNOSTIC AGENTS
41 3701BA ACCU-CHEK INSTANT GLUC (PRI) DIAGNOSTIC DIAGNOSTIC BLOOD GLUCOSE ACCU-CHEK INSTANT 50'S A 42.3 42.2971 PACK 1 BOX PRI PRODUCTOS ROCHE INTERAMERICANA SA STO BRYDEN STOKES LTD B 3626 DIABETES MELLITUS 2024-04-01 2026-03-31 6 DIABETES MELLITUS
42 3701BA ACCU-CHEK INSTANT GLUC (PRI) DIAGNOSTIC DIAGNOSTIC BLOOD GLUCOSE ACCU-CHEK INSTANT 50'S A 42.30 42.30 PACK 1 BOX PRI PRODUCTOS ROCHE INTERAMERICANA SA STO BRYDEN STOKES LTD B 3626 DIABETES MELLITUS 2026-04-01 2028-03-31 6 DIABETES MELLITUS
42 5511AX ACCU-FINE 32G (PRI) PEN NEEDLES PEN NEEDLES ACCU-FINE 100'S B 26.34 0.26 EACH 10 BOX PRI PRODUCTOS ROCHE INTERAMERICANA SA STO BRYDEN STOKES LTD 682008 INSULINS 2026-04-01 0 INSULINS