2010 Medicare Part D Plan Formulary Information |
EnvisionRxPlus Gold (PDP) (S7694-041-0)
Benefit Details
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The EnvisionRxPlus Gold (PDP) (S7694-041-0) Formulary Drugs Starting with the Letter P in CMS PDP Region 7 which includes: VA
|
Drugs Starting with Letter P
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
PACERONE 100MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PACERONE 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PACERONE 200MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PACERONE 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PACERONE 300MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PACERONE 300MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PALGIC 4MG/5ML LIQUID ![Compare how all Medicare Part D PDP plans in VA cover PALGIC 4MG/5ML LIQUID.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PANCRELIPASE TABLET 8000;30000 MG; ![Compare how all Medicare Part D PDP plans in VA cover PANCRELIPASE TABLET 8000;30000 MG;.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
PANRETIN 0.1% GEL 60GM TUBE ![Compare how all Medicare Part D PDP plans in VA cover PANRETIN 0.1% GEL 60GM TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE ![Compare how all Medicare Part D PDP plans in VA cover PANTOPRAZOLE SODIUM 20MG TABLET DELAYED RELEASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT ![Compare how all Medicare Part D PDP plans in VA cover PANTOPRAZOLE SODIUM 40MG TABLET DELAYED RELEASE 90 CRC BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
PARCAINE 0.5% DROPS ![Compare how all Medicare Part D PDP plans in VA cover PARCAINE 0.5% DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PAROXETINE 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in VA cover PAROXETINE 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PAROXETINE FILM COATED 20MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PAROXETINE FILM COATED 20MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PAROXETINE HCL 10MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PAROXETINE HCL 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PAROXETINE HCL 10MG/5ML SUSPENSION ORAL ![Compare how all Medicare Part D PDP plans in VA cover PAROXETINE HCL 10MG/5ML SUSPENSION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PAROXETINE HCL TABLET 24 12.5MG ![Compare how all Medicare Part D PDP plans in VA cover PAROXETINE HCL TABLET 24 12.5MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
PAROXETINE HCL TABLET 24 25MG ![Compare how all Medicare Part D PDP plans in VA cover PAROXETINE HCL TABLET 24 25MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
PAROXETINE TABLETS 30MG 90 BOT ![Compare how all Medicare Part D PDP plans in VA cover PAROXETINE TABLETS 30MG 90 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PASER GRANULES 4GM PACKET ![Compare how all Medicare Part D PDP plans in VA cover PASER GRANULES 4GM PACKET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PATADAY 0.2% DROPS ![Compare how all Medicare Part D PDP plans in VA cover PATADAY 0.2% DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PATANOL 0.1% EYE DROPS ![Compare how all Medicare Part D PDP plans in VA cover PATANOL 0.1% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PEDI-DRI TOPICAL POWDER ![Compare how all Medicare Part D PDP plans in VA cover PEDI-DRI TOPICAL POWDER.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL ![Compare how all Medicare Part D PDP plans in VA cover PEDIARIX SOLUTION INJECTION 25-25-10 10 X .5ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PEDVAXHIB VACCINE VIAL ![Compare how all Medicare Part D PDP plans in VA cover PEDVAXHIB VACCINE VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL ![Compare how all Medicare Part D PDP plans in VA cover PEG 3350/ELECTROLYTE 240-22.72G SOLUTION RECONSTITUTED ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PEGANONE 250MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PEGANONE 250MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PEGASYS 180MCG/0.5ML CONV.PK ![Compare how all Medicare Part D PDP plans in VA cover PEGASYS 180MCG/0.5ML CONV.PK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
25% | N/A | None |
PENICILLIN G POTASSIUM FOR INJECTION ![Compare how all Medicare Part D PDP plans in VA cover PENICILLIN G POTASSIUM FOR INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN G POTASSIUM FOR INJECTION ![Compare how all Medicare Part D PDP plans in VA cover PENICILLIN G POTASSIUM FOR INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL ![Compare how all Medicare Part D PDP plans in VA cover PENICILLIN G SODIUM FOR INJECTION 5000000UNT 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN V POTASSIUM 250MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in VA cover PENICILLIN V POTASSIUM 250MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN V POTASSIUM 250MG/5ML LIQUID ![Compare how all Medicare Part D PDP plans in VA cover PENICILLIN V POTASSIUM 250MG/5ML LIQUID.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN V POTASSIUM 500MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PENICILLIN V POTASSIUM 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT ![Compare how all Medicare Part D PDP plans in VA cover PENICILLIN V POTASSIUM FOR ORAL SOLUTION CONCENTRATE 125MG 200ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PENTAZOCINE/ACETAMIN TABLET ![Compare how all Medicare Part D PDP plans in VA cover PENTAZOCINE/ACETAMIN TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENTAZOCINE/NALOXONE TABLET ![Compare how all Medicare Part D PDP plans in VA cover PENTAZOCINE/NALOXONE TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENTOPAK 400MG TABLET SA ![Compare how all Medicare Part D PDP plans in VA cover PENTOPAK 400MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENTOXIFYLLINE 400MG TABLET SA ![Compare how all Medicare Part D PDP plans in VA cover PENTOXIFYLLINE 400MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PENTOXIL 400MG TABLET SA ![Compare how all Medicare Part D PDP plans in VA cover PENTOXIL 400MG TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PERMETHRIN 5% CREAM ![Compare how all Medicare Part D PDP plans in VA cover PERMETHRIN 5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PERPHENAZINE TABLETS 16MG 100 BOT ![Compare how all Medicare Part D PDP plans in VA cover PERPHENAZINE TABLETS 16MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PERPHENAZINE TABLETS 4MG 100 BOXUD ![Compare how all Medicare Part D PDP plans in VA cover PERPHENAZINE TABLETS 4MG 100 BOXUD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PERPHENAZINE TABLETS 8MG 100 BOT ![Compare how all Medicare Part D PDP plans in VA cover PERPHENAZINE TABLETS 8MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PERPHENAZINE TABLETS USP 2MG 100 BOT ![Compare how all Medicare Part D PDP plans in VA cover PERPHENAZINE TABLETS USP 2MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PFIZERPEN 5MMU VIAL ![Compare how all Medicare Part D PDP plans in VA cover PFIZERPEN 5MMU VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT ![Compare how all Medicare Part D PDP plans in VA cover PHENYTOIN ORAL SUSPENSION 125MG 8 OZ BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PHENYTOIN SODIUM EXTENDED CAPSULES 100MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP ![Compare how all Medicare Part D PDP plans in VA cover PHENYTOIN SODIUM INJECTION 50MG 25 X 2ML AMP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHYSIOLYTE SOLUTION FOR IRRIGATION ![Compare how all Medicare Part D PDP plans in VA cover PHYSIOLYTE SOLUTION FOR IRRIGATION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PHYSIOSOL IRRIGATION SOL ![Compare how all Medicare Part D PDP plans in VA cover PHYSIOSOL IRRIGATION SOL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PILOCARPINE HCL 5MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PILOCARPINE HCL 5MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PILOCARPINE HCL 7.5MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PILOCARPINE HCL 7.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PILOPINE HS 4% EYE GEL ![Compare how all Medicare Part D PDP plans in VA cover PILOPINE HS 4% EYE GEL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PINDOLOL 10MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PINDOLOL 10MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PINDOLOL 5MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PINDOLOL 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PIPERACILLIN 3GM VIAL ![Compare how all Medicare Part D PDP plans in VA cover PIPERACILLIN 3GM VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PIPERACILLIN 40GM BULK VIAL ![Compare how all Medicare Part D PDP plans in VA cover PIPERACILLIN 40GM BULK VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PIROXICAM 10MG CAPSULE ![Compare how all Medicare Part D PDP plans in VA cover PIROXICAM 10MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PIROXICAM 20MG CAPSULE (500 CT) ![Compare how all Medicare Part D PDP plans in VA cover PIROXICAM 20MG CAPSULE (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PLASMA-LYTE 148 IV SOLUTION ![Compare how all Medicare Part D PDP plans in VA cover PLASMA-LYTE 148 IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PLASMA-LYTE 148/DEXTROSE 5% ![Compare how all Medicare Part D PDP plans in VA cover PLASMA-LYTE 148/DEXTROSE 5%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PLASMA-LYTE 56 INJECTION 32;128 MG/100ML; ![Compare how all Medicare Part D PDP plans in VA cover PLASMA-LYTE 56 INJECTION 32;128 MG/100ML;.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PLASMA-LYTE 56/DEXTROSE 5% ![Compare how all Medicare Part D PDP plans in VA cover PLASMA-LYTE 56/DEXTROSE 5%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML; ![Compare how all Medicare Part D PDP plans in VA cover PLASMA-LYTE A PH 7.4 SOLUTION 37;368; MG/100ML;.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PLASMA-LYTE INJ-R ![Compare how all Medicare Part D PDP plans in VA cover PLASMA-LYTE INJ-R.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PLAVIX 75MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PLAVIX 75MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PLAVIX TABLETS 300MG ![Compare how all Medicare Part D PDP plans in VA cover PLAVIX TABLETS 300MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PODOFILOX 0.5% TOPICAL TUBEX ![Compare how all Medicare Part D PDP plans in VA cover PODOFILOX 0.5% TOPICAL TUBEX.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POLY-DEX 3.5-10K-.1 OINTMENT ![Compare how all Medicare Part D PDP plans in VA cover POLY-DEX 3.5-10K-.1 OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POLYCIN-B 500-10KU/G OINTMENT ![Compare how all Medicare Part D PDP plans in VA cover POLYCIN-B 500-10KU/G OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POLYGAM S/D 10GM VL W/DILUENT ![Compare how all Medicare Part D PDP plans in VA cover POLYGAM S/D 10GM VL W/DILUENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
25% | N/A | P |
POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1% ![Compare how all Medicare Part D PDP plans in VA cover POLYMYXIN B SUL-TRIMETHOPRIM 10K U-0.1%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2% ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 0.075%/D5W/SODIUM CHLORIDE 0.2%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3% ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.3%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45% ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 0.15%/D5W/SODIUM CHLORIDE 0.45%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2% ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.2%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 0.3%/D5W/SODIUM CHLORIDE 0.45% 1000ML BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 10MEQ TABLET SA ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 10MEQ TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE 10MEQ/100ML SOL ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 10MEQ/100ML SOL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 10MEQ/50ML SOL ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 10MEQ/50ML SOL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 20MEQ IN D5W LACT RNG ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 20MEQ IN D5W LACT RNG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225% ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 20MEQ IN D5W/NACL 0.225%.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 20MEQ TABLET SR PARTICLES/CRYSTALS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 20MEQ/50ML SOL ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 20MEQ/50ML SOL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 20MEQ/NS 1000ML IV SOLUTION ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 20MEQ/NS 1000ML IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 30MEQ/100ML SOL ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 30MEQ/100ML SOL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 40MEQ IN D5W LACT RNG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
POTASSIUM CHLORIDE 8MEQ TABLET SA ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE 8MEQ TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE ER CAPSULES 10MEQ ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE ER CAPSULES 10MEQ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CHLORIDE ER CPCR 8MEQ ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE ER CPCR 8MEQ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE FOR INJECTION CONCENTRATE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE IN 5% DEXTROSE AND 0.2% NACL SOLUTION FOR INJECTION USP 0.15% 250ML X 24 CASE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE IN 5% DEXTROSE AND NACL SOLUTION FOR INJECTION 0.075% 1000ML PLASTIC BAGS X 12 CA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE IN 5% DEXTROSE AND SODIUM CHLORIDE INJECTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE IN 5% DEXTROSE INJECTION 40 12 X 1000ML CTR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE INJECTION 5-30-.225 12 X 1000ML CTR ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE IN DEXTROSE AND SODIUM CHLORIDE INJECTION 5-30-.225 12 X 1000ML CTR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE IN DEXTROSE INJECTION 5GM/75MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CHLORIDE IN SODIUM CHLORIDE INJECTION 0.15%-0.9% 12 X 1000ML BAG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
POTASSIUM CITRATE 10MEQ TABLET SA ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CITRATE 10MEQ TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
POTASSIUM CITRATE 5MEQ TABLET SA ![Compare how all Medicare Part D PDP plans in VA cover POTASSIUM CITRATE 5MEQ TABLET SA.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRANDIN 0.5MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PRANDIN 0.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PRANDIN 1MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PRANDIN 1MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PRANDIN 2MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PRANDIN 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PRAVASTATIN SODIUM 20MG TABLET 500 BOT ![Compare how all Medicare Part D PDP plans in VA cover PRAVASTATIN SODIUM 20MG TABLET 500 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAVASTATIN SODIUM 40MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in VA cover PRAVASTATIN SODIUM 40MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAVASTATIN SODIUM 80MG TABLET (90 CT) ![Compare how all Medicare Part D PDP plans in VA cover PRAVASTATIN SODIUM 80MG TABLET (90 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAVASTATIN SODIUM TABLETS 10MG 90 BOT ![Compare how all Medicare Part D PDP plans in VA cover PRAVASTATIN SODIUM TABLETS 10MG 90 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAZOSIN 5MG CAPSULE ![Compare how all Medicare Part D PDP plans in VA cover PRAZOSIN 5MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAZOSIN HCL 1MG CAPSULE ![Compare how all Medicare Part D PDP plans in VA cover PRAZOSIN HCL 1MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRAZOSIN HCL 2MG CAPSULE ![Compare how all Medicare Part D PDP plans in VA cover PRAZOSIN HCL 2MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNICARBATE 0.1% CREAM ![Compare how all Medicare Part D PDP plans in VA cover PREDNICARBATE 0.1% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNICARBATE 0.1% OINTMENT ![Compare how all Medicare Part D PDP plans in VA cover PREDNICARBATE 0.1% OINTMENT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE 5MG/5ML TUBEX ![Compare how all Medicare Part D PDP plans in VA cover PREDNISOLONE 5MG/5ML TUBEX.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR ![Compare how all Medicare Part D PDP plans in VA cover PREDNISOLONE ACETATE OPHTHALMIC SUSPENSION 1.0% STERILE 10ML BOTDR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE SOD 1% EYE DROP ![Compare how all Medicare Part D PDP plans in VA cover PREDNISOLONE SOD 1% EYE DROP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in VA cover PREDNISOLONE SODIUM PHOSPHATE 15MG/5ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PREDNISONE 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 1MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PREDNISONE 1MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 2.5MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PREDNISONE 2.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 20MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in VA cover PREDNISONE 20MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 50MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PREDNISONE 50MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREDNISONE 5MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PREDNISONE 5MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREDNISONE 5MG/5ML SOLUTION ![Compare how all Medicare Part D PDP plans in VA cover PREDNISONE 5MG/5ML SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREMARIN 0.3MG (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PREMARIN 0.3MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PREMARIN 0.45MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PREMARIN 0.45MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PREMARIN 0.625MG (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PREMARIN 0.625MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PREMARIN 0.9MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PREMARIN 0.9MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PREMARIN 1.25MG (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PREMARIN 1.25MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PREMARIN 25MG VIAL ![Compare how all Medicare Part D PDP plans in VA cover PREMARIN 25MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PREMARIN VAGINAL CREAM /APPL ![Compare how all Medicare Part D PDP plans in VA cover PREMARIN VAGINAL CREAM /APPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PREMASOL 6% IV SOLUTION ![Compare how all Medicare Part D PDP plans in VA cover PREMASOL 6% IV SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | P |
PREMPHASE 0.625/5MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PREMPHASE 0.625/5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PREMPRO 0.3MG/1.5MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PREMPRO 0.3MG/1.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PREMPRO 0.45/1.5MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PREMPRO 0.45/1.5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PREMPRO 0.625/2.5MG TABLET DIALPK ![Compare how all Medicare Part D PDP plans in VA cover PREMPRO 0.625/2.5MG TABLET DIALPK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PREMPRO 0.625/5MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PREMPRO 0.625/5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT ![Compare how all Medicare Part D PDP plans in VA cover PRENATABS OBN TABLETS 200;1;150;MG;MG;MCG; 90 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREVALITE POW 4GM PK ![Compare how all Medicare Part D PDP plans in VA cover PREVALITE POW 4GM PK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PREZISTA TABLET 600MG ![Compare how all Medicare Part D PDP plans in VA cover PREZISTA TABLET 600MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
25% | N/A | None |
PREZISTA TABLET 75MG ![Compare how all Medicare Part D PDP plans in VA cover PREZISTA TABLET 75MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PREZISTA TABLETS 400MG 60 TABLETS BOT ![Compare how all Medicare Part D PDP plans in VA cover PREZISTA TABLETS 400MG 60 TABLETS BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
25% | N/A | None |
PRIFTIN 150MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PRIFTIN 150MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PRIMIDONE 250MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PRIMIDONE 250MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PRIMIDONE 50MG TABLET (500 CT) ![Compare how all Medicare Part D PDP plans in VA cover PRIMIDONE 50MG TABLET (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PRISTIQ 100MG TABLET SR 24HR ![Compare how all Medicare Part D PDP plans in VA cover PRISTIQ 100MG TABLET SR 24HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PRISTIQ 50MG TABLET SR 24HR ![Compare how all Medicare Part D PDP plans in VA cover PRISTIQ 50MG TABLET SR 24HR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER ![Compare how all Medicare Part D PDP plans in VA cover PROAIR HFA 90MCG HFA AEROSOL WITH ADAPTER.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | Q:27 /30Days |
PROBENECID 500MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PROBENECID 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROBENECID/COLCHICINE TABLET S ![Compare how all Medicare Part D PDP plans in VA cover PROBENECID/COLCHICINE TABLET S.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCAINAMIDE 100MG/ML VIAL ![Compare how all Medicare Part D PDP plans in VA cover PROCAINAMIDE 100MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCAINAMIDE 500MG/ML VIAL ![Compare how all Medicare Part D PDP plans in VA cover PROCAINAMIDE 500MG/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT ![Compare how all Medicare Part D PDP plans in VA cover PROCALAMINE INJECTION 210MG-290MG-26MG 6 X 1000ML BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | P |
PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN ![Compare how all Medicare Part D PDP plans in VA cover PROCHLORPERAZINE EDISYLATE INJECTION 10MG 10 X 2ML VIALS CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROCHLORPERAZINE MALEATE 10MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROCHLORPERAZINE MALEATE 5MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX ![Compare how all Medicare Part D PDP plans in VA cover PROCHLORPERAZINE SUPPOSITORIES 25MG 12 BOX.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCRIT 10000U/ML VIAL ![Compare how all Medicare Part D PDP plans in VA cover PROCRIT 10000U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | P |
PROCRIT 2000U/ML VIAL 6 X 1ML VIAL ![Compare how all Medicare Part D PDP plans in VA cover PROCRIT 2000U/ML VIAL 6 X 1ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | P Q:23 /30Days |
PROCRIT 3000U/ML VIAL ![Compare how all Medicare Part D PDP plans in VA cover PROCRIT 3000U/ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | P Q:16 /30Days |
PROCRIT 40000U/ML VIAL PR ![Compare how all Medicare Part D PDP plans in VA cover PROCRIT 40000U/ML VIAL PR.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
25% | N/A | P |
PROCRIT 4000U/ML VIAL 25 X 1ML VIAL ![Compare how all Medicare Part D PDP plans in VA cover PROCRIT 4000U/ML VIAL 25 X 1ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | P Q:12 /30Days |
PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY ![Compare how all Medicare Part D PDP plans in VA cover PROCRIT SOLUTION FOR INJECTION 20000UNT/ML 24 X 1 ML TRAY.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
25% | N/A | P |
PROCTO-PAK 1% CREAM ![Compare how all Medicare Part D PDP plans in VA cover PROCTO-PAK 1% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCTOCREAM-HC 2.5% CREAM ![Compare how all Medicare Part D PDP plans in VA cover PROCTOCREAM-HC 2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROCTOSOL-HC 2.5% CREAM ![Compare how all Medicare Part D PDP plans in VA cover PROCTOSOL-HC 2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROCTOZONE-HC 2.5% CREAM ![Compare how all Medicare Part D PDP plans in VA cover PROCTOZONE-HC 2.5% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROGLYCEM 50MG/ML ORAL SUSP ![Compare how all Medicare Part D PDP plans in VA cover PROGLYCEM 50MG/ML ORAL SUSP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PROGRAF 0.5MG CAPSULE ![Compare how all Medicare Part D PDP plans in VA cover PROGRAF 0.5MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | P |
PROGRAF 1MG CAPSULE ![Compare how all Medicare Part D PDP plans in VA cover PROGRAF 1MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | P |
PROGRAF 5MG CAPSULE ![Compare how all Medicare Part D PDP plans in VA cover PROGRAF 5MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | P |
PROGRAF 5MG/ML AMPULE ![Compare how all Medicare Part D PDP plans in VA cover PROGRAF 5MG/ML AMPULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | P |
PROLASTIN 500MG VIAL ![Compare how all Medicare Part D PDP plans in VA cover PROLASTIN 500MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PROLEUKIN 22 MILLION UNITS VL ![Compare how all Medicare Part D PDP plans in VA cover PROLEUKIN 22 MILLION UNITS VL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Tier 5 Specialty |
25% | N/A | None |
PROPAFENONE HCL 150MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROPAFENONE HCL 150MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPAFENONE HCL 225MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PROPAFENONE HCL 225MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPAFENONE HCL 300MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROPAFENONE HCL 300MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL 20MG/5ML TUBEX ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL 20MG/5ML TUBEX.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL 40MG/5ML TUBEX ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL 40MG/5ML TUBEX.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL 60MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL 60MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL 80MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL 80MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL 20MG TABLET (1000 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL HCL 20MG TABLET (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL HCL CAPSULES ER 120MG (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL HCL CAPSULES ER 160MG (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL CAPSULES ER 60MG (100 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL HCL CAPSULES ER 60MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL HCL CAPSULES ER 80MG (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL HCL INJECTION 1MG 10 PKG OF 10 CRTN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL HCL TABLET USP 10MG (1000 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL HCL TABLET USP 10MG (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROPRANOLOL HCL TABLET USP 40MG (1000 CT) ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL HCL TABLET USP 40MG (1000 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL/HCTZ 40/25 TABLET ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL/HCTZ 40/25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPRANOLOL/HCTZ 80/25 TABLET ![Compare how all Medicare Part D PDP plans in VA cover PROPRANOLOL/HCTZ 80/25 TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROPYLTHIOURACIL 50MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PROPYLTHIOURACIL 50MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |
PROQUAD VIAL ![Compare how all Medicare Part D PDP plans in VA cover PROQUAD VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PROTONIX IV 40MG VIAL ![Compare how all Medicare Part D PDP plans in VA cover PROTONIX IV 40MG VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None |
PROTOPIC 0.03% OINTMENT 100GM TUBE ![Compare how all Medicare Part D PDP plans in VA cover PROTOPIC 0.03% OINTMENT 100GM TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PROTOPIC 0.1% OINTMENT 60GM TUBE ![Compare how all Medicare Part D PDP plans in VA cover PROTOPIC 0.1% OINTMENT 60GM TUBE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS ![Compare how all Medicare Part D PDP plans in VA cover PROTRIPTYLINE HYDROCHLORIDE TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG ![Compare how all Medicare Part D PDP plans in VA cover PROTRIPTYLINE HYDROCHLORIDE TABLETS 5MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Tier 2 NonPreferred Generics |
$30.00 | $90.00 | None |
PROVENTIL HFA INHALER 90MCG AE ![Compare how all Medicare Part D PDP plans in VA cover PROVENTIL HFA INHALER 90MCG AE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | Q:21 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
PROVIGIL 100MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PROVIGIL 100MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | P |
PROVIGIL 200MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PROVIGIL 200MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | P |
PYRAZINAMIDE 500MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PYRAZINAMIDE 500MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Tier 3 Preferred Brand |
$25.00 | $75.00 | None |
PYRIDOSTIGMINE BROMIDE 60MG TABLET ![Compare how all Medicare Part D PDP plans in VA cover PYRIDOSTIGMINE BROMIDE 60MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
1 |
Tier 1 Preferred Generic |
$4.00 | $12.00 | None |