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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 0014K CHLORPHENIRAMINE 10MG/ML IV/IM INJ (MON/PHA) CHLORPHENIRAMINE CHLORPHENIRAMINE 10X1ML B $6.96 $0.70 INJECTION 0 AMP MON MONTAGE PHARMACEUTICALS PHA PHARMACY SALES CARIBBEAN 0404 FIRST GENERATION ANTIHISTAMINES 2022-04-01 2024-03-31 IV/IM 0 ANTIHISTAMINICS
40 01133 CEFAZOLIN 1G IV/IM INJ (RTM/PHA) CEFAZOLIN CEFAZOLIN 1G VIAL B $3.89 $3.89 INJECTION 0 VIAL RTM PANPHARMA GMBH PHA PHARMACY SALES CARIBBEAN 08120604 FIRST GEN CEPHALOSPORINS 2022-04-01 2024-03-31 IV/IM 6 ANTI-INFECTIVE AGENTS
40 01243 OPTOMYCIN 0.5% EYE DR (ASL/PHA) CHLORAMPHENIC CHLORAMPHENICOL OPTOMYCIN 10ML C $4.08 $4.08 EYE DROP 0 BOTT ASL ASHFORD LABORATORIES LTD PHA PHARMACY SALES CARIBBEAN 520404 EENT ANTIBACTERIALS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 0131DH KLARICID 50MG/ML SUSP (ABB/PHA) CLARITHROMYCI CLARITHROMYCIN KLARICID 60ML C $15.79 $0.26 SUSPENSION 0 ML ABB ABBOTT PHA PHARMACY SALES CARIBBEAN 08121292 OTHER MACROLIDES 2022-04-01 2024-03-31 Oral 0 ANTI-INFECTIVE AGENTS
40 0131DH KLARICID 50MG/ML SUSP (ABB/PHA) CLARITHROMYCI (C) CLARITHROMYCIN KLARICID 60ML C $15.79 $0.26 SUSPENSION ABB ABBOTT PHA PHARMACY SALES CARIBBEAN 8121292 OTHER MACROLIDES 2022-04-01 2023-03-31 Delete from contract Oral 0 OTHER MACROLIDES 2023-03-02
40 0131DJ KLARICID 25MG/ML SUSP (ABB/PHA) CLARITHROMYCI CLARITHROMYCIN KLARICID 60ML C $11.50 $0.19 SUSPENSION 0 ML ABB ABBOTT PHA PHARMACY SALES CARIBBEAN 08121292 OTHER MACROLIDES 2022-04-01 2024-03-31 Oral 0 ANTI-INFECTIVE AGENTS
40 0131DJ KLARICID 25MG/ML SUSP (ABB/PHA) CLARITHROMYCI (C) CLARITHROMYCIN KLARICID 60ML C $11.50 $0.19 SUSPENSION ABB ABBOTT PHA PHARMACY SALES CARIBBEAN 8121292 OTHER MACROLIDES 2022-04-01 2023-03-31 Delete from contract Oral 0 OTHER MACROLIDES 2023-03-02
40 0141FU KLARICID XL 500MG TAB (ABB/PHA) CLARITHROMYCI CLARITHROMYCIN KLARICID XL 10'S C $16.66 $1.67 TABLET 0 TAB ABB ABBOTT PHA PHARMACY SALES CARIBBEAN 08121292 OTHER MACROLIDES 2022-04-01 2024-03-31 Oral 0 ANTI-INFECTIVE AGENTS
40 0141FU KLARICID XL 500MG TAB (ABB/PHA) CLARITHROMYCI (C) CLARITHROMYCIN KLARICID XL 10'S C $16.66 $1.67 TABLET IMMED ABB ABBOTT PHA PHARMACY SALES CARIBBEAN 8121292 OTHER MACROLIDES 2022-04-01 2023-03-31 Delete from contract Oral 0 OTHER MACROLIDES 2023-03-02
40 0141FV KLARICID 500MG TAB (ABB/PHA) CLARITHROMYCIN CLARITHROMYCIN KLARICID 10'S C $16.72 $1.67 TABLET 0 TAB ABB ABBOTT PHA PHARMACY SALES CARIBBEAN 08121292 OTHER MACROLIDES 2022-04-01 2024-03-31 Price Change Oral 0 ANTI-INFECTIVE AGENTS 2022-05-05
40 0164AW AMPICILLIN 500MG INJ (MON/PHA) AMPICILLIN AMPICILLIN 500MG VIAL C $1.69 $1.69 INJECTION 0 VIAL MON MONTAGE PHARMACEUTICALS PHA PHARMACY SALES CARIBBEAN 081216 PENICILLINS 2022-04-01 2024-03-31 IV 0 ANTI-INFECTIVE AGENTS
40 0164C AMPICILLIN 500MG INJ (RTM/PHA) AMPICILLIN AMPICILLIN 500MG VIAL C $1.82 $1.82 INJECTION 0 VIAL RTM PANPHARMA GMBH PHA PHARMACY SALES CARIBBEAN 081216 PENICILLINS 2022-04-01 2024-03-31 IV 0 ANTI-INFECTIVE AGENTS
40 01916 PENICILLIN G SODIUM 1MU INJ (RTM/PHA) PENICILLIN G SODIUM PENICILLIN G SODIUM 15ML B $12.07 $12.07 INJECTION 0 VIAL RTM PANPHARMA GMBH PHA PHARMACY SALES CARIBBEAN 081216 PENICILLINS 2022-04-01 2024-03-31 IV 0 ANTI-INFECTIVE AGENTS
40 01924 PENICILLIN G SODIUM 5MU INJ (RTM/PHA) PENICILLIN G SODIUM PENICILLIN G SODIUM 15ML B $12.07 $12.07 INJECTION 0 VIAL RTM PANPHARMA GMBH PHA PHARMACY SALES CARIBBEAN 081216 PENICILLINS 2022-04-01 2024-03-31 IV 0 ANTI-INFECTIVE AGENTS
40 0211Y MEROPENEM 500MG INJ (ABB/PHA) MEROPENEM MEROPENEM 500MG VIAL BQ $11.50 $11.50 INJECTION 0 VIAL ABB ABBOTT PHA PHARMACY SALES CARIBBEAN 08120708 CARBAPENEMS 2022-04-01 2024-03-31 IV 6 ANTI-INFECTIVE AGENTS
40 0211Y MEROPENEM 500MG INJ (ABB/PHA) (BQ) MEROPENEM MEROPENEM 500MG VIAL BQ $11.50 $11.50 INJECTION ABB ABBOTT PHA PHARMACY SALES CARIBBEAN 8120708 CARBAPENEMS 2022-04-01 2023-03-31 Delete from contract IV 6 CARBAPENEMS 2023-03-02
40 0212BG MEROPENEM 1G INJ (RTM/PHA) MEROPENEM MEROPENEM 20ML VIAL BQ $14.79 $14.79 INJECTION 0 VIAL RTM PANPHARMA GMBH PHA PHARMACY SALES CARIBBEAN 08120708 CARBAPENEMS 2022-04-01 2024-03-31 IV 6 ANTI-INFECTIVE AGENTS
40 0225K CLOXACILLIN 500MG INJ (MON/PHA) CLOXACILLIN CLOXACILLIN 500MG VIAL B $1.58 $1.58 INJECTION 0 VIAL MON MONTAGE PHARMACEUTICALS PHA PHARMACY SALES CARIBBEAN 081216 PENICILLINS 2022-04-01 2024-03-31 IV 6 ANTI-INFECTIVE AGENTS
40 0321AB GENTAMICIN 40MG/ML IV/IM INJ (RTM/PHA) GENTAMICIN GENTAMICIN 10X2ML B $12.48 $1.25 INJECTION 0 AMP RTM PANPHARMA GMBH PHA PHARMACY SALES CARIBBEAN 081202 AMINOGLYCOSIDES 2022-04-01 2022-05-31 IV/IM 6 ANTI-INFECTIVE AGENTS
40 0321AB GENTAMICIN 40MG/ML IV/IM INJ (RTM/PHA) GENTAMICIN GENTAMICIN 10X2ML B $19.27 $1.93 INJECTION 0 AMP RTM PANPHARMA GMBH PHA PHARMACY SALES CARIBBEAN 081202 AMINOGLYCOSIDES 2022-06-01 2024-03-31 Price Change IV/IM 6 ANTI-INFECTIVE AGENTS 2022-05-31