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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 09116 SPIRIVA RESPIMAT 2.5MCG INHR (BOE/STO) TIOTRO TIOTROPIUM SPIRIVA RESPIMAT 60 DOSES BQ 111.29 111.29 INHALER 0 INHR BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 481208 ANTICHOLINERGIC AGENTS (RESPIRATORY) 2022-04-01 2024-03-31 ORAL INHALATION 6 RESPIRATORY TRACT AGENTS
41 09116 SPIRIVA RESPIMAT 2.5MCG INHR (BOE) TIOTR (BQ) TIOTROPIUM SPIRIVA RESPIMAT 60 DOSES BQ 121.59 121.5906 INHR 1 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 481208 ANTICHOLINERGIC AGENTS (RESPIRATORY) 2024-04-01 2026-03-31 ORAL INHALATION 6 ANTICHOLINERGIC AGENTS (RESPIRATORY)
42 09116 SPIRIVA RESPIMAT 2.5MCG INHR (BOE) TIOTR TIOTROPIUM SPIRIVA RESPIMAT 60 DOSES BQ 121.59 121.59 INHR 1 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 481208 ANTICHOLINERGIC AGENTS (RESPIRATORY) 2026-04-01 ORAL INHALATION 0 ANTICHOLINERGIC AGENTS (RESPIRATORY)
40 09118 SPIOLTO RESPIMAT 2.5/2.5MCG INHR (BOE/STO) TI OLODATEROL|TIOTROPIUM SPIOLTO RESPIMAT 60 DOSES BQ 111.29 111.29 INHALER 1 INHR BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 481208 ANTICHOLINERGIC AGENTS (RESPIRATORY) 2022-04-01 2024-03-31 ORAL INHALATION 6 RESPIRATORY TRACT AGENTS
41 09118 SPIOLTO RESPIMAT 2.5MCG|2.5MCG INHR (BOE) OLODATEROL|TIOTROP (BQ) OLODATEROL|TIOTROPIUM SPIOLTO RESPIMAT 60 DOSES BQ 121.59 121.5906 INHR 1 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 481208 ANTICHOLINERGIC AGENTS (RESPIRATORY) 2024-04-01 2026-03-31 ORAL INHALATION 6 ANTICHOLINERGIC AGENTS (RESPIRATORY)
42 09118 SPIOLTO RESPIMAT 2.5MCG|2.5MCG INHR (BOE) OLODATEROL|TIOTROP OLODATEROL|TIOTROPIUM SPIOLTO RESPIMAT 60 DOSES BQ 121.59 121.59 INHR 1 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 481208 ANTICHOLINERGIC AGENTS (RESPIRATORY) 2026-04-01 ORAL INHALATION 0 ANTICHOLINERGIC AGENTS (RESPIRATORY)
40 55314 TWYNSTA 5MG | 80MG TAB (BOE/STO) AMLODIPINE | TELMISARTAN AMLODIPINE|TELMISARTAN TWYNSTA 28'S A 25.12 0.90 TABLET 30 TAB BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD B 240892 HYPOTENSIVE AGENTS, MISCELLANEOUS 2022-04-01 2024-03-31 Oral 6 CARDIOVASCULAR DRUGS
41 55314 TWYNSTA 5MG|80MG TAB (BOE) AMLODIPINE|TELMISARTAN AMLODIPINE|TELMISARTAN TWYNSTA 28'S A 25.12 0.897 TAB 30 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD B 240892 HYPOTENSIVE AGENTS, MISCELLANEOUS 2024-04-01 2026-03-31 ORAL 6 HYPOTENSIVE AGENTS, MISCELLANEOUS
42 55314 TWYNSTA 5MG|80MG TAB (BOE) AMLODIP (C) AMLODIPINE|TELMISARTAN TWYNSTA 28'S A 25.12 0.90 TAB 30 BLIS BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD B 240892 HYPOTENSIVE AGENTS, MISCELLANEOUS 2026-04-01 ORAL 6 HYPOTENSIVE AGENTS, MISCELLANEOUS
40 55324 TWYNSTA 10MG | 80MG TAB (BOE/STO) AMLODIPINE | TELMISARTAN AMLODIPINE|TELMISARTAN TWYNSTA 28'S A 25.12 0.90 TABLET 30 TAB BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD B 240892 HYPOTENSIVE AGENTS, MISCELLANEOUS 2022-04-01 2024-03-31 Oral 6 CARDIOVASCULAR DRUGS
41 55324 TWYNSTA 10MG|80MG TAB (BOE) AMLODIPINE|TELMISARTAN AMLODIPINE|TELMISARTAN TWYNSTA 28'S A 25.12 0.897 TAB 30 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD B 240892 HYPOTENSIVE AGENTS, MISCELLANEOUS 2024-04-01 2026-03-31 ORAL 6 HYPOTENSIVE AGENTS, MISCELLANEOUS
42 55324 TWYNSTA 10MG|80MG TAB (BOE) AMLODI (C) AMLODIPINE|TELMISARTAN TWYNSTA 28'S A 25.12 0.90 TAB 30 BLIS BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD B 240892 HYPOTENSIVE AGENTS, MISCELLANEOUS 2026-04-01 ORAL 6 HYPOTENSIVE AGENTS, MISCELLANEOUS
42 5962A TRAJENTAMET 2.5MG|850MG TAB (BOE) LINAGLIPTIN|METFORMIN LINAGLIPTIN|METFORMIN TRAJENTAMET 60'S C 114.66 1.91 TAB 0 BLIS BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 682005 DIPEPTIDYL PEPTIDASE INHIBITORS 2026-04-01 ORAL 0 DIPEPTIDYL PEPTIDASE INHIBITORS
42 5963Q TRAJENTAMET 2.5MG|1000MG TAB (BOE) LINAGLIPTIN|METFORMIN LINAGLIPTIN|METFORMIN TRAJENTAMET 60'S C 114.66 1.91 TAB 0 BLIS BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 682005 DIPEPTIDYL PEPTIDASE INHIBITORS 2026-04-01 ORAL 0 DIPEPTIDYL PEPTIDASE INHIBITORS
40 72017 METALYSE 50MG INJ (BOE/STO) TENECTEPLASE TENECTEPLASE METALYSE 50MG VIAL BQ 2,535.76 2,535.76 INJECTION 0 VIAL BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 201220 THROMBOLYTIC AGENTS 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 72017 METALYSE 50MG INJ (BOE) TENECTEPLASE (BQ) TENECTEPLASE METALYSE 50MG VIAL BQ 2873 2872.9966 VIAL 0 VIAL BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 201220 THROMBOLYTIC AGENTS 2024-04-01 2026-03-31 IV 0 THROMBOLYTIC AGENTS
42 72017 METALYSE 50MG INJ (BOE) TENECTEPLASE TENECTEPLASE METALYSE 50MG VIAL BQ 2,873.00 2,873.00 VIAL 0 VIAL BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 201220 THROMBOLYTIC AGENTS 2026-04-01 IV 0 THROMBOLYTIC AGENTS
40 76712 ACTILYSE 50MG INJ (BOE/STO) ALTEPLASE ALTEPLASE ACTILYSE 2X50MG BQ 4,817.93 2,408.97 INJECTION 0 VIAL BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 201220 THROMBOLYTIC AGENTS 2022-04-01 2024-03-31 IV 0 BLOOD FORMATION, COAGULATION AND THROMBOSIS
41 76712 ACTILYSE 50MG INJ (BOE) ALTEPLASE (BQ) ALTEPLASE ACTILYSE 2X50MG BQ 5307.23 2653.6143 VIAL 0 BOX BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 201220 THROMBOLYTIC AGENTS 2024-04-01 2026-03-31 IV 0 THROMBOLYTIC AGENTS
42 76712 ACTILYSE 50MG INJ (BOE) ALTEPLASE ALTEPLASE ACTILYSE 2X50MG BQ 5,307.23 2,653.62 VIAL 0 VIAL BOE BOEHRINGER INGELHEIM STO BRYDEN STOKES LTD 201220 THROMBOLYTIC AGENTS 2026-04-01 IV 0 THROMBOLYTIC AGENTS