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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 5201FS LIFESTYLES ULTRA THIN (ANS/SBI) CONDOM CONDOM LIFESTYLES ULTRA THIN 3'S C $3.59 $1.20 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 2022-06-12 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 5201FS LIFESTYLES ULTRA THIN (ANS/SBI) CONDOM CONDOM LIFESTYLES ULTRA THIN 3'S C $5.77 $1.92 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-06-14 2024-03-31 Price Change IV 0 HORMONES AND SYNTHETIC SUBSTITUTES 2022-06-13
40 5201FT LIFESTYLES SKYN ORIGINAL (ANS/SBI) CONDOM CONDOM LIFESTYLES SKYN ORIGINAL 3'S C $3.13 $1.04 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 5201FT LIFESTYLES SKYN ORIGINAL (ANS/SBI) CONDOM CONDOM LIFESTYLES SKYN ORIGINAL 3'S C $5.98 $1.99 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-06-14 2024-03-31 Price Change IV 0 HORMONES AND SYNTHETIC SUBSTITUTES 2022-06-13
40 5201FU LIFESTYLE SKYN LRG (ANS/SBI) CONDOM CONDOM LIFESTYLE SKYN LRG 3'S C $4.24 $1.41 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 2022-06-12 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 5201FU LIFESTYLE SKYN LRG (ANS/SBI) CONDOM CONDOM LIFESTYLE SKYN LRG 3'S C $5.98 $1.99 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-06-14 2024-03-31 Price Change IV 0 HORMONES AND SYNTHETIC SUBSTITUTES 2022-06-13
40 5201FV LIFESTYLES SKYN SELLECTION (ANS/SBI) CONDOM CONDOM LIFESTYLES SKYN SELLECTION 3'S C $4.24 $1.41 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 2022-07-25 Delete from contract IV 0 HORMONES AND SYNTHETIC SUBSTITUTES 2022-06-13
40 5201FW LIFESTYLES SENSITIVE VARIETY (ANS/SBI) CON CONDOM LIFESTYLES SENSITIVE VARIETY 3'S C $3.59 $1.20 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 2022-06-12 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 5201FW LIFESTYLES SENSITIVE VARIETY (ANS/SBI) CON CONDOM LIFESTYLES SENSITIVE VARIETY 3'S C $5.77 $1.92 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-06-14 2024-03-31 Price Change IV 0 HORMONES AND SYNTHETIC SUBSTITUTES 2022-06-13
40 5201FX LIFEESTYLES HOT RIDER (ANS/SBI) CONDOM CONDOM LIFEESTYLES HOT RIDER 3'S C $3.59 $1.20 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 2024-03-31 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 5201FY LIFESTYLES STUDDED (ANS/SBI) CONDOM CONDOM LIFESTYLES STUDDED 1000'S C $123.52 $0.12 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 2024-03-31 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 5201FZ LIFESTYLES ULTRA SENSITIVE (ANS/SBI) CONDOM CONDOM LIFESTYLES ULTRA SENSITIVE 3'S C $2.53 $0.84 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 2022-06-12 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 5201FZ LIFESTYLES ULTRA SENSITIVE (ANS/SBI) CONDOM CONDOM LIFESTYLES ULTRA SENSITIVE 3'S C $2.10 $0.70 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-06-14 2024-03-31 Price Change IV 0 HORMONES AND SYNTHETIC SUBSTITUTES 2022-06-13
40 5201GA LIFESTYLES KYNG GOLD (ANS/SBI) CONDOM CONDOM LIFESTYLES KYNG GOLD 3'S C $5.77 $1.92 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-06-13 2024-03-31 Price Change IV 0 HORMONES AND SYNTHETIC SUBSTITUTES 2022-06-13
40 5201GB LIFESTYLES FLAVORS/COLORS (ANS/SBI) CONDOM CONDOM LIFESTYLES FLAVORS|COLORS 1000'S C $123.52 $0.12 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 2024-03-31 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 5201GC LIFESTYLES ULTRA RIBBED (ANS/SBI) CONDOM CONDOM LIFESTYLES ULTRA RIBBED 3'S C $2.53 $0.84 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 2022-06-12 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 5201GC LIFESTYLES ULTRA RIBBED (ANS/SBI) CONDOM CONDOM LIFESTYLES ULTRA RIBBED 3'S C $2.10 $0.70 0 EACH ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-06-13 2024-03-31 Price Change IV HORMONES AND SYNTHETIC SUBSTITUTES 2022-06-13
40 5201N LIFESTYLES STUDDED (ANS/SBI) CONDOM CONDOM LIFESTYLES STUDDED 3'S C $3.59 $3.59 0 PACK ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 2022-06-12 0 HORMONES AND SYNTHETIC SUBSTITUTES
40 5201N LIFESTYLES STUDDED (ANS/SBI) CONDOM CONDOM LIFESTYLES STUDDED 3'S C $6.16 $6.16 0 PACK ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-06-14 2024-03-31 Price Change 0 HORMONES AND SYNTHETIC SUBSTITUTES 2022-06-13
40 5201Q LIFESTYLES BARE RIDER (ANS/SBI) CONDOM CONDOM LIFESTYLES BARE RIDER 3'S C $3.59 $3.59 0 PACK ANS ANSELL HEALTHCARE SBI MASSY DISTRIBUTION (BDOS) LTD 6813 CONDOMS 2022-04-01 IV 0 HORMONES AND SYNTHETIC SUBSTITUTES