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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 41458 ACULAR LS 0.4% EYE DR (ALL/COL) KETOROLAC KETOROLAC ACULAR LS 5ML C 26.64 26.64 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 520820 EENT NSAID 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 41458 ACULAR LS 0.4% EYE DR (ALL) KETOROLAC (C) KETOROLAC ACULAR LS 5ML C 26.64 26.6396 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5208 EENT ANTI-INFLAMMATORY AGENTS 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT ANTI-INFLAMMATORY AGENTS
42 41458 ACULAR LS 0.4% EYE DR (ALL) KETOROLAC KETOROLAC ACULAR LS 5ML C 26.64 26.64 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL AVENTA BARBADOS 5208 EENT ANTI-INFLAMMATORY AGENTS 2026-04-01 OPHTHALMIC 0 EENT ANTI-INFLAMMATORY AGENTS
40 47014 REFRESH LIQUIGEL 1% EYE DR (ALL/COL) HYPROMEL CARBOXYMETHYLCELLULOSE REFRESH LIQUIGEL 15ML A 11.55 11.55 EYE DROP 1 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 47014 REFRESH LIQUIGEL 1% EYE DR (ALL) HYPROME (B) CARBOXYMETHYLCELLULOSE REFRESH LIQUIGEL 15ML B 11.55 11.5529 BOTT 1 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
42 47014 REFRESH LIQUIGEL 1% EYE DR (ALL) HYPROME CARBOXYMETHYLCELLULOSE REFRESH LIQUIGEL 15ML B 11.55 11.55 BOTT 1 BOTT ALL ALLERGAN INTERNATIONAL COL AVENTA BARBADOS 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
40 4701AV REFRESH OPTIVE GEL 1% | 0.9% EYE DR (ALL/COL) CARBOXYMETHYLCELLULOSE | GLYCERINE CARBOXYMETHYLCELLULOSE|GLYCERINE REFRESH OPTIVE GEL 10ML C 12.91 12.91 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701AV REFRESH OPTIVE GEL 1%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULO (C) CARBOXYMETHYLCELLULOSE|GLYCERINE REFRESH OPTIVE GEL 10ML C 12.91 12.912 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
42 4701AV REFRESH OPTIVE GEL 1%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULO CARBOXYMETHYLCELLULOSE|GLYCERINE REFRESH OPTIVE GEL 10ML C 12.91 12.91 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL AVENTA BARBADOS 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
40 4701B REFRESH TEARS 0.5% EYE DR (ALL/COL) HYPROMELL HYPROMELLOSE REFRESH TEARS 15ML C 11.55 11.55 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701B REFRESH TEARS 0.5% EYE DR (ALL) CARBOXYMETHYLCELLULOSE (C) CARBOXYMETHYLCELLULOSE REFRESH TEARS 15ML C 11.55 11.5529 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
42 4701B REFRESH TEARS 0.5% EYE DR (ALL) CARBOXYMETHYLCELLULOSE CARBOXYMETHYLCELLULOSE REFRESH TEARS 15ML C 11.55 11.55 BOTT 1 BOTT ALL ALLERGAN INTERNATIONAL COL AVENTA BARBADOS 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
40 4701K OPTIVE .05%C/0.9%G EYE DR (ALL/COL) CARBOXY/G CARBOXYMETHYLCELLULOSE|GLYCERINE OPTIVE 15ML C 13.59 13.59 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701K OPTIVE 0.5%|0.9% EYE DR (ALL) CARBOXYMETHYLCELLULOSE|GLYCERI (C) CARBOXYMETHYLCELLULOSE|GLYCERINE OPTIVE 15ML C 13.59 13.5916 BOTT 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT DRUGS MISCELLANEOPUS
40 59511 PRED-FORTE 1% EYE DR (ALL/COL) PREDNISOLONE PREDNISOLONE PRED-FORTE 5ML C 17.67 17.67 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5208 EENT ANTI-INFLAMMATORY AGENTS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 59511 PRED-FORTE 1% EYE DR (ALL) PREDNISOLONE (C) PREDNISOLONE PRED-FORTE 5ML C 17.67 17.6691 BOTT 1 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5208 EENT ANTI-INFLAMMATORY AGENTS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT ANTI-INFLAMMATORY AGENTS
42 59511 PRED-FORTE 1% EYE DR (ALL) PREDNISOLONE PREDNISOLONE PRED-FORTE 5ML C 17.67 17.67 BOTT 1 BOTT ALL ALLERGAN INTERNATIONAL COL AVENTA BARBADOS 5208 EENT ANTI-INFLAMMATORY AGENTS 2026-04-01 OPHTHALMIC 6 EENT ANTI-INFLAMMATORY AGENTS
40 61211 COMBIGAN 0.2% | 0.5% EYE DR (ALL/COL) BRIMONIDINE | TIMOLOL BRIMONIDINE|TIMOLOL COMBIGAN 5ML C 37.11 37.11 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 61211 COMBIGAN 0.2%|0.5% EYE DR (ALL) BRIMONIDINE|TIMOLOL (C) BRIMONIDINE|TIMOLOL COMBIGAN 5ML C 37.11 37.1051 BOTT 1 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2024-04-01 2026-03-31 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
42 61211 COMBIGAN 0.2%|0.5% EYE DR (ALL) BR (C) BRIMONIDINE|TIMOLOL COMBIGAN 5ML C 37.11 37.11 BOTT 1 BOTT ALL ALLERGAN INTERNATIONAL COL AVENTA BARBADOS B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2026-04-01 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS