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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
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 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
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
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
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
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
40 64231 RESTASIS 0.05% EYE (ALL/COL) CYCLOSPORIN CYCLOSPORIN RESTASIS 30X0.4ML C $67.96 $2.27 EYE DROP 0 AMP ALL ALLERGAN INTERNATIONAL COL COLLINS LTD 520892 EENT ANTI INFLAMMATORY AGENTS MISCELLANEOUS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 A2712 FML LIQUIFILM 0.1% EYE DR (ALL/COL) FLUOROMET FLUOROMETHOLONE FML LIQUIFILM 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
40 A4921 ALPHAGAN P 0.1% EYE DR (ALL/COL) BRIMONIDINE BRIMONIDINE ALPHAGAN P 10ML C $45.94 $45.94 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD B 524004 EENT ALPHA ADRENERGIC AGONISTS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS
40 A531J LUMIGAN 0.01% EYE DR (ALL/COL) BIMATOPROST BIMATOPROST LUMIGAN 2.5ML C $41.32 $41.32 EYE DROP 0 BOTT ALL ALLERGAN INTERNATIONAL COL COLLINS LTD B 524028 EENT PROSTAGLANDIN ANALOGS 2022-04-01 2024-03-31 OPHTHALMIC 0 EYE, EAR, NOSE AND THROAT PREPARATIONS