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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
41 23132 MIOSTAT OCULAR 0.01% INJ (ALC/AHI) CARBACHOL CARBACHOL MIOSTAT OCULAR 1.5ML VIAL BQ 55.18 55.182 ML 0 VIAL ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 524020 EENT MIOTICS IV 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 23132 MIOSTAT OCULAR 0.01% INJ (ALC/AHI) CARBACHOL CARBACHOL MIOSTAT OCULAR 1.5ML VIAL BQ 59.94 59.94 INJECTION 0 VIAL ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 524020 EENT MIOTICS 2022-04-01 2024-03-31 IV 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 3362E COLCHICINE 0.5MG TAB (HAL/COL) COLCHICINE COLCHICINE 100'S A 22.40 0.22 TABLET 90 TAB HAL HALEWOOD CHEMICALS LTD. COL COLLINS LTD 4040 URICOSURIC AGENTS 2022-04-01 2024-03-31 Oral 6 ELECTROLYTIC, CALORIC, AND WATER BALANCE
41 3541AB VITALUX PLUS 10000U|2MG TAB (ALC/AHI) MULTIVITAMINS MULTIVITAMINS VITALUX PLUS 30'S C 28.62 0.9541 TAB 0 TAB ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 8828 MULTIVITAMIN PREPARATIONS ORAL 0 VITAMINS
41 40418 B.S.S. SOLN (ALC/AHI) BALANCED SALT BALANCED SALT B.S.S. 15ML BQ 12.99 12.9936 SOLN 10 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 40418 B.S.S. SOLN (ALC/AHI) BALANCED SALT BALANCED SALT B.S.S. 15ML BQ 12.67 12.67 SOLUTION 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 40439 B.S.S. PLUS SOLN (ALC/AHI) BALANCED SALT SOL BALANCED SALT B.S.S. PLUS 500ML BQ 32.48 32.48 SOLUTION 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4043A B.S.S (BAG) SOLN (ALC/AHI) BALANCED SALT BALANCED SALT B.S.S (BAG) 500ML BQ 29.9 29.9016 SOLN 10 BAG ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 4043A B.S.S (BAG) SOLN (ALC/AHI) BALANCED SALT BALANCED SALT B.S.S (BAG) 500ML BQ 29.33 29.33 SOLUTION 0 BAG ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5236 EENT UNCLASSIFIED 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 41458 ACULAR LS 0.4% EYE DR (ALL/COL) KETOROLAC KETOROLAC ACULAR LS 5ML C 26.64 26.6396 EYE DR 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5208 EENT ANTI-INFLAMMATORY AGENTS OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
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 42312 SILVER NITRATE 95% STICK (HAL/COL) SILVER NITRATE SILVER NITRATE 12'S B 93.21 7.7676 STICK 2 EACH HAL HALEWOOD CHEMICALS LTD. COL COLLINS LTD 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS
40 42312 SILVER NITRATE 95% STICK (HAL/COL) SILVER NITRATE SILVER NITRATE 12'S B 108.60 9.05 STICK 0 EACH HAL HALEWOOD CHEMICALS LTD. COL COLLINS LTD 8436 MUCOUS-SKIN PREPARATIONS,MISCE LLANEOUS 2022-04-01 2024-03-31 TOPICAL 0 SKIN-MUCOUS MEMBRANE PREPARATIONS
41 47014 REFRESH LIQUIGEL 1% EYE DR (ALL/COL) HYPROMEL CARBOXYMETHYLCELLULOSE REFRESH LIQUIGEL 15ML B 11.55 11.5529 EYE DR 1 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 5292 EENT DRUGS MISCELLANEOPUS OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
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
40 4701AP TEARS NATURALE FORTE EYE DR (ALC/AHI) DEXTRAN | GLYCERINE | HYPROMELLOSE DEXTRAN|GLYCERINE|HYPROMELLOSE TEARS NATURALE FORTE 15ML C 13.32 13.32 EYE DROP 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701AQ TEARS NATURALE II 0.1%|0.3% EYE DR (ALC/AHI) DEXTRAN|HYPROMELLOSE DEXTRAN 70|HYPROMELLOSE TEARS NATURALE II 15ML C 17.89 17.8866 EYE DR 1 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 4701AQ TEARS NATURALE II 0.1% | 0.3% EYE DR (ALC/AHI) DEXTRAN | HYPROMELLOSE DEXTRAN 70|HYPROMELLOSE TEARS NATURALE II 15ML C 12.67 12.67 EYE DROP 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
41 4701AR SYSTANE 0.4%|0.3% EYE DR (ALC/AHI) POLYETHYLENE GLYCOL 400|PROPYLENE GLYCOL POLYETHYLENE GLYCOL 400|PROPYLENE GLYCOL SYSTANE 15ML C 20.25 20.2515 EYE DR 1 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS OPHTHALMIC 6 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 4701AR SYSTANE 0.4% | 0.3% EYE DR (ALC/AHI) POLYETHYLENE GLYCOL 400 | PROPYLENE GLYCOL POLYETHYLENE GLYCOL 400|PROPYLENE GLYCOL SYSTANE 15ML C 17.75 17.75 EYE DROP 0 BOTT ALC ALCON LABORATORIES INC. AHI ARMSTRONG HEALTHCARE INC 5292 EENT DRUGS MISCELLANEOPUS 2022-04-01 2024-03-31 Ophthalmic 0 EYE, EAR, NOSE AND THROAT PREPARATIONS