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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 00521 XELODA 500MG TAB (ROC/AHI) CAPECITABINE CAPECITABINE XELODA 120'S C 326.20 2.72 TABLET 0 TAB ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 Oral 0 ANTINEOPLASTICS
41 0451Z BACTRIM FORTE 800MG|160MG TAB (ROC) SULFAMETHOXAZOLE|TRIMETH (B) SULFAMETHOXAZOLE|TRIMETHOPRIM BACTRIM FORTE 10'S B 11.42 1.1417 TAB 28 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 081220 SULPHONAMIDES 2024-04-01 2026-03-31 ORAL 0 SULPHONAMIDES
41 04536 BACTRIM 80MG|16MG/ML INJ (ROC) SULFAMETHOXAZOLE|TRIMETHOPRIM (C) SULFAMETHOXAZOLE|TRIMETHOPRIM BACTRIM 10X5ML C 10.6 1.0602 AMP 0 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 081220 SULPHONAMIDES 2024-04-01 2026-03-31 IV 0 SULPHONAMIDES
40 36223 PROLOPA 50MG | 200MG TAB (ROC/AHI) BENSERAZIDE | BENSERAZIDE|LEVODOPA PROLOPA 30'S A 40.77 1.36 TABLET 240 TAB ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 283616 DOPAMINE PRECURSORS 2022-04-01 2024-03-31 Oral 6 CENTRAL NERVOUS SYSTEM DRUGS
41 36223 PROLOPA 50MG|200MG TAB (ROC) BENSERAZIDE|LEVODOPA BENSERAZIDE|LEVODOPA PROLOPA 30'S A 30.15 1.005 TAB 240 BOX ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 283616 DOPAMINE PRECURSORS 2024-09-27 2026-03-31 ORAL 6 DOPAMINE PRECURSORS 2024-09-27
40 41811 MABTHERA 10MG/ML INJ (ROC/AHI) RITUXIMAB RITUXIMAB MABTHERA 100MG VIAL C 1,391.78 1,391.78 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 41811 MABTHERA 10MG/ML INJ (ROC) RITUXIMAB (BQ) RITUXIMAB MABTHERA 100MG VIAL BQ 1391.78 1391.7819 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
40 4181A AVASTIN 25MG/ML INJ (ROC/AHI) BEVACIZUMAB BEVACIZUMAB AVASTIN 100MG VIAL C 1,003.06 1,003.06 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181A AVASTIN 25MG/ML INJ (ROC) BEVACIZUMAB (C) BEVACIZUMAB AVASTIN 100MG VIAL C 1003.06 1003.0616 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
40 4181B AVASTIN 25MG/ML INJ (ROC/AHI) BEVACIZUMAB BEVACIZUMAB AVASTIN 400MG VIAL C 4,012.25 4,012.25 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181B AVASTIN 25MG/ML INJ (ROC) BEVACIZUMAB (C) BEVACIZUMAB AVASTIN 400MG VIAL C 4012.25 4012.2462 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
40 4181BB MABTHERA 10MG/ML INJ (ROC/AHI) RITUXIMAB RITUXIMAB MABTHERA 50ML C 3,479.45 3,479.45 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181BB MABTHERA 10MG/ML INJ (ROC) RITUXIMA (BQ) RITUXIMAB MABTHERA 50ML BQ 3479.45 3479.4547 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
40 4181BC MABTHERA SC 1400MG INJ (ROC/AHI) RITUXIMAB RITUXIMAB MABTHERA SC 11.7ML C 4,392.81 4,392.81 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181BC MABTHERA SC 1400MG INJ (ROC) RITUXIMAB (BQ) RITUXIMAB MABTHERA SC 11.7ML BQ 4392.81 4392.8116 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 IV 0 ANTINEOPLASTICS
41 4181BL PHESGO 60MG/ML|60MG/ML INJ (ROC) PERTUZUMAB|TRASTUZUMAB (C) PERTUZUMAB|TRASTUZUMAB PHESGO 10ML C 12626.62 12626.62 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 9244 IMMUNOSUPPRESSIVE AGENTS 2024-04-01 2026-03-31 SC 0 IMMUNOSUPPRESSIVE AGENTS
41 4181BW PHESGO 1200MG|600MG INJ (ROC) PERTUZUMAB|TRASTUZUMAB (C) PERTUZUMAB|TRASTUZUMAB PHESGO 15ML VIAL C 21270.89 21270.885 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2024-04-01 2026-03-31 SC 0 ANTINEOPLASTICS
40 4181C ACTEMRA 20MG/ML INJ (ROC/AHI) TOCILIZUMAB TOCILIZUMAB ACTEMRA 10ML VIAL C 706.76 706.76 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS
41 4181C ACTEMRA 20MG/ML INJ (ROC) TOCILIZUMAB (C) TOCILIZUMAB ACTEMRA 10ML VIAL C 706.76 706.7642 VIAL 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 9236 DISEASE MODIFYING ANTIRHEUMATIC AGENTS 2024-04-01 2026-03-31 IV 0 DISEASE MODIFYING ANTIRHEUMATIC AGENTS
40 4181D ACTEMRA 20MG/ML INJ (ROC/AHI) TOCILIZUMAB TOCILIZUMAB ACTEMRA 4ML VIAL C 282.71 282.71 INJECTION 0 VIAL ROC ROCHE SERVICIOS S.A. AHI ARMSTRONG HEALTHCARE INC 1000 ANTINEOPLASTICS 2022-04-01 2024-03-31 IV 0 ANTINEOPLASTICS