2011 Medicare Part D Plan Formulary Information |
Freedom VIP Savings COPD (HMO SNP) (H5427-077-0)
Benefit Details
|
The Freedom VIP Savings COPD (HMO SNP) (H5427-077-0) Formulary Drugs Starting with the Letter M in Citrus County, FL: CMS MA Region 9 which includes: FL
|
Drugs Starting with Letter M
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
M-M-R II VACCINE W/DILUENT 1 DOSE/0.5ML |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MAGENSIUM SULFATE IN 5% DEXTROSE INJECTION 5-1 24 X 100ML CTR |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MALARONE 62.5-25MG PED TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MAPROTILINE 25MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MAPROTILINE 50MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MAPROTILINE 75MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MARPLAN 10MG TABLET (100 CT) |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MATULANE 50MG CAPSULE |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MAXALT 10MG TABLET 12 CRTN |
3 |
Tier 3 |
$60.00 | $120.00 | Q:12 /25Days |
MAXALT 5MG TABLET 12 CRTN |
3 |
Tier 3 |
$60.00 | $120.00 | Q:12 /25Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MAXALT MLT 10MG TABLET 4X3 UNIT DOSE CASE |
3 |
Tier 3 |
$60.00 | $120.00 | Q:12 /25Days |
MAXALT MLT 5MG TABLET 4X3 UNIT CASE |
3 |
Tier 3 |
$60.00 | $120.00 | Q:12 /25Days |
MEBENDAZOLE 100MG TABLET CHEW |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE 2.5MG |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | Q:1 /90Days |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MEGACE ES 625MG/5ML SUSP |
3 |
Tier 3 |
$60.00 | $120.00 | Q:600 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEGESTROL 20MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MEGESTROL ACETATE 400MG/10ML SUSPENSION ORAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MELOXICAM 15MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
MELOXICAM TABLETS 7.5MG |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
MENACTRA INJECTION 4MCG/0.5ML 5 X .5ML SYR |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MENOMUNE-A/C/Y/W-135 VIAL |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MENOSTAR 14 MCG/DAY PATCH |
2 |
Tier 2 |
$20.00 | $40.00 | Q:4 /30Days |
MENVEO INJECTION KIT |
3 |
Tier 3 |
$60.00 | $120.00 | None |
MEPERIDINE 10MG/ML SYRINGE |
1 |
Tier 1 |
$0.00 | $0.00 | P |
MEPERIDINE 50MG/5ML SYRUP |
1 |
Tier 1 |
$0.00 | $0.00 | Q:450 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEPERIDINE HCL 50MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:240 /30Days |
MEPERIDINE HCL TABLET 100MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days |
MEPROBAMATE 200MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days |
MEPROBAMATE 400MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:240 /30Days |
MEPRON 750MG/5ML ORAL SUSP |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MERCAPTOPURINE 50MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MERREM INJECTION 500MG 10X20MLVIALS VIAL |
3 |
Tier 3 |
$60.00 | $120.00 | P |
MERUVAX II VACCINE/DILUENT |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MESALAMINE 4G/60ML ENEMA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MESNA INJECTION 1GM/ML 10ML VIALMD CRTN |
1 |
Tier 1 |
$0.00 | $0.00 | P |
MESNEX 400MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MESTINON 180MG TIMESPAN |
3 |
Tier 3 |
$60.00 | $120.00 | None |
MESTINON 60MG/5ML SYRUP |
3 |
Tier 3 |
$60.00 | $120.00 | None |
MESTINON TABLETS 60MG 100 BOT |
3 |
Tier 3 |
$60.00 | $120.00 | None |
METAPROTERENOL 10MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
METAPROTERENOL 10MG/5ML SYR |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METAPROTERENOL 20MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METFORMIN HCL 850MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METFORMIN HCL ER 750MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
METHADONE HCL ORAL CONCENTRATE 10MG 946ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
1 |
Tier 1 |
$0.00 | $0.00 | P |
METHADONE HYDROCHLORIDE TABLETS 10 MG |
1 |
Tier 1 |
$0.00 | $0.00 | Q:360 /30Days |
METHAZOLAMIDE 25MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHAZOLAMIDE 50MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHENAMINE HIPPURATE 1G TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHERGINE 0.2MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
METHIMAZOLE TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHIMAZOLE TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHITEST 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHOCARBAMOL 500MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHOCARBAMOL 750MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHOTREXATE 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | P |
METHOTREXATE INJECTION 25 MG/ML |
1 |
Tier 1 |
$0.00 | $0.00 | P |
METHYCLOTHIAZIDE 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHYLDOPA 250MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHYLDOPA 500MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHYLDOPA/HCTZ 250-15 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHYLDOPA/HCTZ 250-25 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHYLDOPATE 250MG/5ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
METHYLIN ER 10MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHYLIN ER 20MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
METHYLPHENIDATE 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
METHYLPHENIDATE 20MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
METHYLPHENIDATE 5MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:90 /30Days |
METHYLPREDNISOLONE 4 MG ORAL TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METIPRANOLOL 0.3% EYE DROPS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOCLOPRAMIDE HYDROCHLORIDE TABLETS 10MG 500 BOTPL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOCLOPRAMIDE INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | P |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOCLOPRAMIDE TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOLAZONE 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOLAZONE 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOLAZONE 5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOPROLOL SUCCINATE 25MG TABLET SR 24HR |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
METOPROLOL SUCCINATE 50MG TABLET SR 24HR |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
METOPROLOL SUCCINATE TABLETS EXTENDED RELEASE 100MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
METOPROLOL SUCINNATE TABLETS EXTENDED RELEASE 200MG 1000 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD |
1 |
Tier 1 |
$0.00 | $0.00 | P |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METRONIDAZOLE 0.75% CREAM |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METRONIDAZOLE 0.75% LOTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METRONIDAZOLE 375MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METRONIDAZOLE INJECTION |
3 |
Tier 3 |
$60.00 | $120.00 | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METRONIDAZOLE VAGINAL GEL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MEXILETINE 150MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MEXILETINE 200MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MEXILETINE 250MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIACALCIN 200IU/ML VIAL |
3 |
Tier 3 |
$60.00 | $120.00 | P |
MICARDIS 20MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | S Q:30 /30Days |
MICARDIS 40MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | S Q:30 /30Days |
MICARDIS 80MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | S Q:30 /30Days |
MICARDIS HCT 40/12.5MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | S Q:30 /30Days |
MICARDIS HCT 80/12.5MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | S Q:30 /30Days |
MICARDIS HCT 80/25MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | S Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MICROGESTIN 1.5-0.03MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIDODRINE HCL 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIDODRINE HCL 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIGERGOT 2-100MG SUPPOSITORY RECTAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MILLIPRED TABLETS 5MG |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MINITRAN 0.1MG/HR PATCH 30 EA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
MINITRAN 0.2MG/HR PATCH 30 EA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
MINITRAN 0.4MG/HR PATCH 30 EA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
MINITRAN 0.6MG/HR PATCH 30 EA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
MINOCYCLINE 100MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINOCYCLINE 50MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MINOCYCLINE HCL 100MG TABLET 60 EA |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MINOCYCLINE HCL 75MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MINOXIDIL 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MINOXIDIL 2.5MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIRTAZAPINE 15MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIRTAZAPINE TABLET 7.5MG (30 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MIRTAZAPINE TABLETS 45MG 30 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MISOPROSTOL 100MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MISOPROSTOL 200MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
2 |
Tier 2 |
$20.00 | $40.00 | P |
MOMETASONE FUROATE CREAM 0.1% 45GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MOMETASONE FUROATE OINTMENT 0.1% 45GM TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MOMETASONE FUROATE TOPICAL SOLUTION 0.1% |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MONUROL PAK GRANULES 3 GM |
3 |
Tier 3 |
$60.00 | $120.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 100MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
MORPHINE SULFATE 15MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
MORPHINE SULFATE 200MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
MORPHINE SULFATE 30MG TABLET SA |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
MORPHINE SULFATE INJECTION 0.5MG 5X10ML VIALGL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MORPHINE SULFATE INJECTION 1MG 5X10ML VIALGL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
MORPHINE SULFATE TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MORPHINE SULFATE TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
MULTAQ DRONEDARONE TABLETS 400MG 60 BOT |
3 |
Tier 3 |
$60.00 | $120.00 | None |
MUPIROCIN 2% OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MUSTARGEN 10MG VIAL |
2 |
Tier 2 |
$20.00 | $40.00 | P |
MYCAMINE 50MG VIAL |
3 |
Tier 3 |
$60.00 | $120.00 | None |
MYCOBUTIN 150MG CAPSULE |
2 |
Tier 2 |
$20.00 | $40.00 | None |
MYCOPHENOLATE MOFETIL CAPSULES 250MG 100 BOT |
2 |
Tier 2 |
$20.00 | $40.00 | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
2 |
Tier 2 |
$20.00 | $40.00 | P |
MYFORTIC 180MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | P |
MYFORTIC 360MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | P |
MYOZYME 50MG VIAL |
4 |
Tier 4 |
33% | 33% | None |
MYTELASE 10MG CAPLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |