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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 12012 GLAUCOTENSIL TD 2% | 0.5% EYE DR (LPO/COL) DORZ DORZOLAMIDE|TIMOLOL GLAUCOTENSIL TD 5ML A 12.23 12.23 EYE DROP 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 12012 GLAUCOTENSIL TD 2%|0.5% EYE DR (LPO) DORZOLAMIDE|TIMOLOL DORZOLAMIDE|TIMOLOL GLAUCOTENSIL TD 5ML A 13.46 13.4557 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2024-04-01 2026-03-31 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
42 12012 GLAUCOTENSIL TD 2%|0.5% EYE DR (LPO) DORZOLAMIDE|TIMOLOL DORZOLAMIDE|TIMOLOL GLAUCOTENSIL TD 5ML B 19.03 19.03 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL AVENTA BARBADOS B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2026-04-01 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
40 36551 BRIXIA 0.05% EYE DR (LPO/COL) AZELASTINE AZELASTINE BRIXIA 6ML A 6.25 6.25 EYE DROP 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5202 ANTIALLERGIC AGENTS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 36551 BRIXIA 0.05% EYE DR (LPO) AZELASTINE AZELASTINE BRIXIA 6ML A 6.88 6.8774 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5202 ANTIALLERGIC AGENTS 2024-04-01 2026-03-31 OPHTHALMIC 6 ANTIALLERGIC AGENTS
42 36551 BRIXIA 0.05% EYE DR (LPO) AZELASTINE AZELASTINE BRIXIA 6ML A 19.03 19.03 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL AVENTA BARBADOS 5202 ANTIALLERGIC AGENTS 2026-04-01 OPHTHALMIC 6 ANTIALLERGIC AGENTS
40 40517 POENCANIA 0.5% EYE DR (LPO/COL) PROPARACAINE PROPARACAINE POENCANIA 10ML A 8.43 8.43 EYE DROP 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5216 EENT LOCAL ANESTHETIC 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 4073X POENTIMOL 0.5% EYE DR (LPO/COL) TIMOLOL TIMOLOL POENTIMOL 5ML C 5.44 5.44 EYE DROP 0 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 524008 EENT BETA ADRENERGIC AGENTS 2022-04-01 2024-03-31 Add to Contract as Cat C OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS 2022-04-01
41 4701BA AUCIC 1% EYE DR (LPO) CARBOXYMETHYLCELLULOSE CARBOXYMETHYLCELLULOSE AUCIC 10ML A 8.26 8.2637 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
40 4701F DROPSTAR 0.4% EYE DR (LPO/COL) SOD. HYALURONA SODIUM HYALURONATE DROPSTAR 10ML A 7.61 7.61 EYE DROP 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701F DROPSTAR 0.4% EYE DR (LPO) SOD. HYALURON (C) SODIUM HYALURONATE DROPSTAR 10ML C 8.37 8.3724 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
40 4701T ACRYLARM 0.2% GEL (LPO/COL) POLYACRYLIC ACID POLYACRYLIC ACID ACRYLARM 10G B 11.15 11.15 GEL 1 TUBE LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701T ACRYLARM 0.2% GEL (LPO) POLYACRYLIC ACID (B) POLYACRYLIC ACID ACRYLARM 10G B 12.26 12.2596 TUBE 1 BOX LPO LABORATORIOS POEN S.A. COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS 2024-04-01 2026-03-31 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
42 4701T ACRYLARM 0.2% GEL (LPO) POLYACRYLIC ACID POLYACRYLIC ACID ACRYLARM 10G B 20.39 20.39 TUBE 1 BOX LPO LABORATORIOS POEN S.A. COL AVENTA BARBADOS 5292 EENT DRUGS MISCELLANEOPUS 2026-04-01 OPHTHALMIC 6 EENT DRUGS MISCELLANEOPUS
40 51313 LOUTEN T 0.005% | 0.5% EYE DR (LPO/COL) LATANOP LATANOPROST|TIMOLOL LOUTEN T 2.5ML A 13.05 13.05 EYE DROP 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 51313 LOUTEN T 0.005%|0.5% EYE DR (LPO) LATANO LATANOPROST|TIMOLOL LOUTEN T 2.5ML A 14.35 14.3528 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2024-04-01 2026-03-31 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
42 51313 LOUTEN T 0.005%|0.5% EYE DR (LPO) LATANOPROST|TIMOLOL LATANOPROST|TIMOLOL LOUTEN T 2.5ML C 17.67 17.67 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL AVENTA BARBADOS B 524092 ANTIGLAUCOMA AGENTS MISCELLANEOUS 2026-04-01 OPHTHALMIC 6 ANTIGLAUCOMA AGENTS MISCELLANEOUS
40 5281AA VISAG 0.1% EYE DR (LPO/COL) AZITHROMYCIN AZITHROMYCIN VISAG 2.5ML BQ 8.43 8.43 EYE DROP 0 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 520404 EENT ANTIBACTERIALS 2022-04-01 2024-03-31 OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 5281AA VISAG 0.1% EYE DR (LPO) AZITHROMYCIN (BQ) AZITHROMYCIN VISAG 2.5ML BQ 8.43 8.4268 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL COLLINS LTD 520404 EENT ANTIBACTERIALS 2024-04-01 2026-03-31 OPHTHALMIC 0 EENT ANTIBACTERIALS
42 5281AA VISAG 0.1% EYE DR (LPO) AZITHROMYCIN AZITHROMYCIN VISAG 2.5ML BQ 20.39 20.39 BOTT 1 BOTT LPO LABORATORIOS POEN S.A. COL AVENTA BARBADOS 520404 EENT ANTIBACTERIALS 2026-04-01 OPHTHALMIC 0 EENT ANTIBACTERIALS