2012 Medicare Part D Plan Formulary Information |
Triple-S Medicare Selecto with Medicare Platino (HMO SNP) (H4012-003-0)
Benefit Details
|
The Triple-S Medicare Selecto with Medicare Platino (HMO SNP) (H4012-003-0) Formulary Drugs Starting with the Letter A in Penuelas County, PR: CMS MA Region 0 which includes: PR
|
Drugs Starting with Letter A
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
A-HYDROCORT 100MG VIAL |
1 |
Tier 1 |
15% | 15% | None |
ABILIFY 10MG TABLET |
2 |
Tier 2 |
15% | 15% | S |
ABILIFY 15MG TABLET |
2 |
Tier 2 |
15% | 15% | S |
ABILIFY 1MG/ML SOLUTION |
2 |
Tier 2 |
15% | 15% | S |
ABILIFY 20MG TABLET |
2 |
Tier 2 |
15% | 15% | S |
ABILIFY 2MG TABLET |
2 |
Tier 2 |
15% | 15% | S |
ABILIFY 30MG TABLET |
2 |
Tier 2 |
15% | 15% | S |
ABILIFY 5MG TABLET (OTSUKA) |
2 |
Tier 2 |
15% | 15% | S |
ABILIFY DISCMELT 10MG TABLET |
2 |
Tier 2 |
15% | 15% | S |
ABILIFY DISCMELT 15MG TABLET |
2 |
Tier 2 |
15% | 15% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acarbose 100mg/1 90 TABLET in 1 BOTTLE, |
1 |
Tier 1 |
15% | 15% | None |
acarbose 50 mg tablet |
1 |
Tier 1 |
15% | 15% | None |
ACARBOSE TABLETS |
1 |
Tier 1 |
15% | 15% | None |
ACEBUTOLOL 200MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ACEBUTOLOL 400MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE |
2 |
Tier 2 |
15% | 15% | None |
Acetaminophen and Codeine Phosphate 300; 60mg/1; mg/1 500 TABLET in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE SOLUTION ORAL USP 120;12MG/5ML;MG/ 12.5 ML CUPUD |
1 |
Tier 1 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETAZOLAMIDE 125MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ACETAZOLAMIDE 250MG TABLET (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ACETIC ACID 2% SOLUTION NON-ORAL |
1 |
Tier 1 |
15% | 15% | None |
ACETYLCYSTEINE 10% VIAL |
1 |
Tier 1 |
15% | 15% | P |
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN |
1 |
Tier 1 |
15% | 15% | P |
ACTHIB VACCINE VIAL 10-24UNT/5ML |
2 |
Tier 2 |
15% | 15% | None |
ACTOS 15MG TABLET |
2 |
Tier 2 |
15% | 15% | S |
ACTOS 30MG TABLET (500 CT) |
2 |
Tier 2 |
15% | 15% | S |
ACTOS 45MG TABLET |
2 |
Tier 2 |
15% | 15% | S |
Acyclovir 200mg/1 |
1 |
Tier 1 |
15% | 15% | None |
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Acyclovir 400mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Acyclovir 800mg/1 100 BLISTER PACK in 1 BOX / 1 TABLET in 1 BLISTER PACK |
1 |
Tier 1 |
15% | 15% | None |
ADVAIR DISKUS MIS 100/50 |
2 |
Tier 2 |
15% | 15% | None |
ADVAIR DISKUS MIS 250/50 |
2 |
Tier 2 |
15% | 15% | None |
ADVAIR DISKUS MIS 500/50 |
2 |
Tier 2 |
15% | 15% | None |
ADVAIR HFA 230; 21ug/1; ug/1 120 AEROSOL, METERED in 1 INHALER |
2 |
Tier 2 |
15% | 15% | None |
ADVAIR HFA INHALER 115;21MCG;MCG 120ACTN INHL |
2 |
Tier 2 |
15% | 15% | None |
ADVAIR HFA INHALER 45;21MCG;MCG 120 ACTN INHL |
2 |
Tier 2 |
15% | 15% | None |
AGGRENOX 25-200MG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
AK-CON 0.1% EYE DROPS |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR |
1 |
Tier 1 |
15% | 15% | P |
ALBUTEROL SULFATE SOLUTION FOR INHALATION |
1 |
Tier 1 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL SULFATE TABLET 2MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
ALBUTEROL TABLET 4MG (500 CT) |
1 |
Tier 1 |
15% | 15% | None |
ALCLOMETASONE DIPROPIONATE 0.05% CREAM |
1 |
Tier 1 |
15% | 15% | None |
Alclometasone Dipropionate 0.5mg/g 1 TUBE in 1 CARTON / 60 g in 1 TUBE |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM 40MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM 5MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM 70mg/1 |
1 |
Tier 1 |
15% | 15% | None |
ALENDRONATE SODIUM TABLET 35MG 20 CRTN |
1 |
Tier 1 |
15% | 15% | None |
Allopurinol 300mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET in 1 BLISTER PACK |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ALLOPURINOL TABLETS |
1 |
Tier 1 |
15% | 15% | None |
ALPHAGAN P 0.1% DROPS |
2 |
Tier 2 |
15% | 15% | None |
AMANTADINE 100MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMIKACIN 250MG/ML VIAL |
1 |
Tier 1 |
15% | 15% | P |
AMIKACIN 50MG/ML VIAL |
1 |
Tier 1 |
15% | 15% | P |
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Aminophylline 25mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIA |
1 |
Tier 1 |
15% | 15% | P |
AMINOSYN II 4.25% IN D10W |
1 |
Tier 1 |
15% | 15% | P |
AMINOSYN II 4.25% IN D20W |
1 |
Tier 1 |
15% | 15% | P |
AMINOSYN II 4.25%-D25W IV |
1 |
Tier 1 |
15% | 15% | P |
AMINOSYN II 8.5% ELECTROLYT |
1 |
Tier 1 |
15% | 15% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMINOSYN M 3.5% IV SOLUTION |
1 |
Tier 1 |
15% | 15% | P |
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5% |
1 |
Tier 1 |
15% | 15% | P |
AMINOSYN-HF 8% IV SOLUTION |
1 |
Tier 1 |
15% | 15% | P |
AMIODARONE HCL 400MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Amiodarone hydrochloride 200mg/1 |
1 |
Tier 1 |
15% | 15% | None |
AMITIZA 8MCG CAPSULE |
2 |
Tier 2 |
15% | 15% | None |
AMITIZA CAPSULES 24MCG 60 CAP BOT |
2 |
Tier 2 |
15% | 15% | None |
AMITRIPTYLINE HCL 100MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 10MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 150 MG TAB |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMITRIPTYLINE HCL TABLETS 50MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE 10MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE 5MG TABLET (90 CT) |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE AND BENAZEPRIL HYDROCHLORIDE CAPSULES |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE-BENAZEPRIL 10MG-20MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE-BENAZEPRIL 2.5MG-10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5-10MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
AMLODIPINE BESYLATE-BENAZEPRIL 5MG-20MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMMONIUM LACTATE 12% CREAM |
1 |
Tier 1 |
15% | 15% | None |
AMMONIUM LACTATE 12% LOTION |
1 |
Tier 1 |
15% | 15% | None |
Amnesteem 10mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
1 |
Tier 1 |
15% | 15% | None |
Amnesteem 20mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
1 |
Tier 1 |
15% | 15% | None |
Amnesteem 40mg/1 3 BLISTER PACK in 1 CARTON / 10 CAPSULE in 1 BLISTER PACK |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-K CLV 500-125 MG TAB |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 125MG TABLET CHEW |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 250MG CAPSULE |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Amoxicillin 250mg/1 500 TABLET, CHEWABLE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 50 MG/ML / CLAVULANATE 12.5 MG/ML ORAL SUSPENSION |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN 875MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS 875;125MG;MG 20 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN AND CLAVULANATE POTASSIUM TABLETS EXTENDED RELEASE 1000;62.5MG;MG |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN CAP 500MG |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT |
1 |
Tier 1 |
15% | 15% | None |
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPHETAMINE SALT COMBO 12.5MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
AMPHETAMINE SALT COMBO 15MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
AMPHETAMINE SALT COMBO 30MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
AMPHETAMINE SALT COMBO 7.5MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
AMPHETAMINE SALTS 20MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
AMPHETAMINE SALTS 5 MG TAB |
1 |
Tier 1 |
15% | 15% | P |
amphotericin b 50mg/10mL 10 mL in 1 VIAL |
1 |
Tier 1 |
15% | 15% | P |
AMPICILLIN CAPSULES 250MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMPICILLIN CAPSULES 500MG 100 BOT |
1 |
Tier 1 |
15% | 15% | None |
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT |
2 |
Tier 2 |
15% | 15% | None |
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AMPICILLIN POWDER FOR INJECTION 1 GM/ML |
1 |
Tier 1 |
15% | 15% | P |
Anagrelide Hydrochloride 0.5mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Anagrelide Hydrochloride 1mg/1 100 CAPSULE in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
ANASTROZOLE TABLETS |
1 |
Tier 1 |
15% | 15% | None |
ANDROGEL 1%(50MG) GEL PACKET |
2 |
Tier 2 |
15% | 15% | None |
Androgel 16.2mg/g 1 BOTTLE, PUMP in 1 CARTON / 88 g in 1 BOTTLE, PUMP |
2 |
Tier 2 |
15% | 15% | None |
ASACOL 400mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | None |
ASACOL HD 800mg/1 12 BOTTLE in 1 CASE / 180 TABLET, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | None |
Ascomp with Codeine 325; 50; 40; 30mg/1; mg/1; mg/1; mg/1 500 CAPSULE in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
ASMANEX 220ug/1 1 POUCH in 1 POUCH / 1 INHALER in 1 POUCH / 14 INHALANT in 1 INHALER |
2 |
Tier 2 |
15% | 15% | None |
ASMANEX TWISTHALER 110 MCG #30 |
2 |
Tier 2 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ASMANEX TWISTHALER 220MCG #120 |
2 |
Tier 2 |
15% | 15% | None |
ASMANEX TWISTHALER 220MCG #30 |
2 |
Tier 2 |
15% | 15% | None |
ASMANEX TWISTHALER 220MCG #60 |
2 |
Tier 2 |
15% | 15% | None |
ASTEPRO 0.15% NASAL SPRAY 30 ML |
2 |
Tier 2 |
15% | 15% | None |
ATENOLOL 100mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
Atenolol 25mg/1 100 TABLET in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL TABLET USP 50MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT) |
1 |
Tier 1 |
15% | 15% | None |
ATORVASTATIN 10 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ATORVASTATIN 20 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ATORVASTATIN 40 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
ATORVASTATIN 80 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Atovaquone and Proguanil Hydrochloride 250; 100mg/1; mg/1 |
1 |
Tier 1 |
15% | 15% | None |
ATROVENT HFA AER 17MCG |
2 |
Tier 2 |
15% | 15% | None |
AUGMENTED BETAMETHASONE DIPROPIONATE OINTMENT |
1 |
Tier 1 |
15% | 15% | None |
AVALIDE 300-25MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVANDAMET 1000; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVANDAMET 1000; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVANDAMET 500; 2mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVANDAMET 500; 4mg/1; mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVANDARYL 1; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AVANDARYL 2; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVANDARYL 2; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVANDARYL 4; 4mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVANDARYL 4; 8mg/1; mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVANDIA 2mg/1 60 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVANDIA 4mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVANDIA 8mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
2 |
Tier 2 |
15% | 15% | S |
AVELOX 400MG TABLET |
2 |
Tier 2 |
15% | 15% | None |
AVIANE 0.1-0.02 TABLET |
1 |
Tier 1 |
15% | 15% | None |
AZATHIOPRINE 50MG TABLET |
1 |
Tier 1 |
15% | 15% | P |
AZELASTINE 137 MCG NASAL SPRAY |
1 |
Tier 1 |
15% | 15% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL |
1 |
Tier 1 |
15% | 15% | None |
AZITHROMYCIN 250 MG TABLET |
1 |
Tier 1 |
15% | 15% | None |
Azithromycin 500mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
Azithromycin 600mg/1 30 TABLET, FILM COATED in 1 BOTTLE |
1 |
Tier 1 |
15% | 15% | None |
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT |
2 |
Tier 2 |
15% | 15% | S |