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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 0314L BACTIGRAS 10CMX10CM (SMN/IMS) CHLORHEXIDINE CHLORHEXIDINE BACTIGRAS 10'S A 29.00 2.90 10 EACH SMN SMITH & NEPHEW PHARMACEUTICALS IMS ISLANDS MEDICAL SUPPLIES INC 840492 ANTI-INFECTIVES TOPICAL MISCELLANEOUS 2022-04-06 2024-03-31 Add to Contract as Cat A TOPICAL 6 SKIN-MUCOUS MEMBRANE PREPARATIONS 2022-04-06
41 0314L BACTIGRAS 10CMX10CM (SMN) CHLORHEXIDINE CHLORHEXIDINE BACTIGRAS 10'S A 31.75 3.175 EACH 10 BOX SMN SMITH & NEPHEW PHARMACEUTICALS IMS ISLANDS MEDICAL SUPPLIES INC 840492 ANTI-INFECTIVES TOPICAL MISCELLANEOUS 2024-04-01 2026-03-31 TOPICAL 0 ANTI-INFECTIVES TOPICAL MISCELLANEOUS
40 05752 ENDOXAN 1G INJ (ASM/COL) CYCLOPHOSPHAMIDE CYCLOPHOSPHAMIDE ENDOXAN 1G VIAL BQ 38.06 38.06 INJECTION 0 VIAL ASM ASTA MEDICA AG COL COLLINS LTD 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
40 33811 INTRASITE GEL GEL (SMN/IMS) HYPROMELLOSE | PROPYLENE GLYCOL HYPROMELLOSE|PROPYLENE GLYCOL INTRASITE GEL 10X25G B 133.50 13.35 GEL 0 TUBE SMN SMITH & NEPHEW PHARMACEUTICALS IMS ISLANDS MEDICAL SUPPLIES INC 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2022-04-01 2024-03-31 TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS
41 33811 INTRASITE GEL GEL (SMN) HYPROMELLOSE|PROPYLENE GLYCOL HYPROMELLOSE|PROPYLENE GLYCOL INTRASITE GEL 10X25G B 139.99 13.9994 TUBE 0 BOX SMN SMITH & NEPHEW PHARMACEUTICALS IMS ISLANDS MEDICAL SUPPLIES INC 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2024-04-01 2026-03-31 TOPICAL 0 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS