2012 Medicare Part D Plan Formulary Information |
Freedom VIP Savings (HMO SNP) (H5427-072-0)
Benefit Details
|
The Freedom VIP Savings (HMO SNP) (H5427-072-0) Formulary Drugs Starting with the Letter L in Citrus County, FL: CMS MA Region 9 which includes: FL
|
Drugs Starting with Letter L
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRU |
3 |
Tier 3 |
$60.00 | $120.00 | None |
L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE 16 VACCINE 0.04 MG/ML / L1 PROTEIN, HUMAN PAPILLOMAVIRUS TYPE |
3 |
Tier 3 |
$60.00 | $120.00 | None |
LABETALOL HCL 100MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LABETALOL HCL 200MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LABETALOL HCL 300MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LABETALOL HCL 5MG/20ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
LACRISERT OPTHALMIC INSERT 5MG 60 BLPK |
3 |
Tier 3 |
$60.00 | $120.00 | None |
LACTATED RINGERS INJECTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LACTULOSE SOLUTION ORAL 10GM/15ML 946ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LAMICTAL 25MG TABLET STARTER KIT |
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 |
LAMICTAL KIT 100;25MG;MG |
3 |
Tier 3 |
$60.00 | $120.00 | None |
LAMICTAL TABLET STARTER KIT |
3 |
Tier 3 |
$60.00 | $120.00 | None |
LAMOTRIGINE 150MG TABLET (60 CT) |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LAMOTRIGINE 200MG TABLET (60 CT) |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LAMOTRIGINE 25MG TABLET (100 CT) |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LAMOTRIGINE 25MG TABLET DISPERSIBLE |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LAMOTRIGINE 5MG TABLET DISPERSIBLE |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LAMOTRIGINE TABLET 100MG (100 CT) |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LANOXIN PED 0.1MG/ML AMPUL |
3 |
Tier 3 |
$60.00 | $120.00 | P |
LANREOTIDE 240 MG/ML PREFILLED SYRINGE [SOMATULINE] |
4 |
Tier 4 |
33% | 33% | P |
Lansoprazole 15mg/1 30 CAPSULE, DELAYED RELEASE PELLETS in 1 BOTTLE, PLASTIC |
2 |
Tier 2 |
$20.00 | $40.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lansoprazole 30mg/1 30 CAPSULE, DELAYED RELEASE in 1 BOTTLE |
2 |
Tier 2 |
$20.00 | $40.00 | Q:30 /30Days |
LANTUS 100U/ML VIAL |
2 |
Tier 2 |
$20.00 | $40.00 | Q:40 /30Days |
LANTUS SOLOSTAR INJECTION |
3 |
Tier 3 |
$60.00 | $120.00 | Q:40 /30Days |
LATANOPROST OPHTHALMIC SOLUTION .005% |
1 |
Tier 1 |
$0.00 | $0.00 | Q:3 /25Days |
LATUDA 20 MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | Q:90 /90Days |
Latuda 40mg/1 |
3 |
Tier 3 |
$60.00 | $120.00 | Q:90 /90Days |
Latuda 80mg/1 |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LEFLUNOMIDE 10MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LEFLUNOMIDE TABLETS |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Lessina 3 POUCH in 1 CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER PACK |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LETAIRIS 10MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LETAIRIS 5MG TABLET |
4 |
Tier 4 |
33% | 33% | P |
Letrozole 2.5mg/1 500 TABLET, FILM COATED in 1 BOTTLE, PLASTIC |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEUCOVORIN CALCIUM 100MG VL |
2 |
Tier 2 |
$20.00 | $40.00 | P |
LEUCOVORIN CALCIUM 10MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
Leucovorin Calcium 15mg/1 24 TABLET in 1 BOTTLE |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LEUCOVORIN CALCIUM 25MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LEUCOVORIN CALCIUM 5MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LEUKERAN 2MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LEUKINE 500 MCG/ML |
4 |
Tier 4 |
33% | 33% | P |
LEUKINE INJECTION 250 MCG/ML |
4 |
Tier 4 |
33% | 33% | P |
LEUPROLIDE ACETATE INJECTION |
2 |
Tier 2 |
$20.00 | $40.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVAQUIN 250mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET, FILM COATED in 1 BLISTER PACK |
3 |
Tier 3 |
$60.00 | $120.00 | Q:14 /14Days |
LEVAQUIN 500mg/1 50 TABLET, FILM COATED in 1 BOTTLE |
3 |
Tier 3 |
$60.00 | $120.00 | Q:14 /14Days |
LEVAQUIN 750 MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | Q:14 /14Days |
LEVAQUIN INJECTION 25 MG/ML |
3 |
Tier 3 |
$60.00 | $120.00 | P |
LEVEMIR 100UNITS/ML VIAL |
2 |
Tier 2 |
$20.00 | $40.00 | Q:40 /30Days |
Levemir 14.2mg/mL 5 SYRINGE, PLASTIC in 1 CARTON / 3 mL in 1 SYRINGE, PLASTIC |
3 |
Tier 3 |
$60.00 | $120.00 | Q:40 /30Days |
LEVETIRACETAM 100 MG/ML SOLN 100MG/ML 16 FL OZ BOT |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LEVETIRACETAM 500 MG TABLET 120 BOT |
2 |
Tier 2 |
$20.00 | $40.00 | Q:120 /30Days |
LEVETIRACETAM INJECTION |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LEVETIRACETAM TABLETS 1000MG 60 BOT |
2 |
Tier 2 |
$20.00 | $40.00 | Q:90 /30Days |
LEVETIRACETAM TABLETS 250MG 500 BOT |
2 |
Tier 2 |
$20.00 | $40.00 | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEVETIRACETAM TABLETS 750MG 500 BOT |
2 |
Tier 2 |
$20.00 | $40.00 | Q:120 /30Days |
LEVOBUNOLOL 0.25% EYE DROPS |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOBUNOLOL HYDROCHLORIDE OPHTHALMIC SOLUTION |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOCARNITINE 100MG/ML SOLUTION ORAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
LEVOCARNITINE 200MG/ML VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
Levofloxacin 250mg/1 |
2 |
Tier 2 |
$20.00 | $40.00 | Q:14 /14Days |
Levofloxacin 500mg/1 |
2 |
Tier 2 |
$20.00 | $40.00 | Q:14 /14Days |
Levofloxacin 750mg/1 |
2 |
Tier 2 |
$20.00 | $40.00 | Q:14 /14Days |
LEVOTHYROXINE SODIUM .075MG TABLET (1000 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM .150MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 100MCG 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 |
LEVOTHYROXINE SODIUM 112MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 125MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 137MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 175MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 200MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 25MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 300MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 50MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEVOTHYROXINE SODIUM 88MCG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LEXAPRO 10MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LEXAPRO 20MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LEXAPRO 5MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LEXAPRO 5MG/5ML SOLUTION |
3 |
Tier 3 |
$60.00 | $120.00 | Q:600 /30Days |
LEXIVA 50mg/mL 225 mL in 1 BOTTLE |
3 |
Tier 3 |
$60.00 | $120.00 | None |
LEXIVA TABLETS |
4 |
Tier 4 |
33% | 33% | None |
LIDOCAINE 5% OINTMENT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LIDOCAINE 70 MG / TETRACAINE 70 MG TRANSDERMAL PATCH [SYNERA] |
3 |
Tier 3 |
$60.00 | $120.00 | None |
LIDOCAINE HCL 0.5% VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | P |
LIDOCAINE HCL 2% JELLY 30ML TUBE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LIDOCAINE HCL TOPICAL SOLUTION 4% 50ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LIDOCAINE HYDROCHLORIDE ORAL TOPICAL SOLUTION 20MG 100 ML BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LIDOCAINE-PRILOCAINE 2.5%-2.5% CREAM |
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 |
LIDODERM 5% PATCH |
2 |
Tier 2 |
$20.00 | $40.00 | Q:90 /30Days |
LINCOCIN 300MG/ML VIAL |
2 |
Tier 2 |
$20.00 | $40.00 | None |
liothyronine sodium 10ug/mL 1 VIAL in 1 CARTON / 1 mL in 1 VIAL |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 25MCG 100 TABLETS BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 50MCG 100 TABLETS BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LIOTHYRONINE SODIUM TABLETS 5MCG 100 TABLETS BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LIPITOR 10MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | S Q:30 /30Days |
LIPITOR 20MG TABLET (5000 CT) |
2 |
Tier 2 |
$20.00 | $40.00 | S Q:30 /30Days |
LIPITOR 40MG TABLET (500 CT) |
2 |
Tier 2 |
$20.00 | $40.00 | S Q:30 /30Days |
LIPITOR 80MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | S Q:30 /30Days |
LISINOPRIL 10MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Lisinopril 2.5mg 100 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LISINOPRIL 20MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LISINOPRIL 30MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LISINOPRIL 40MG TABLET (500 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
Lisinopril 5mg/1 1000 TABLET in 1 BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LISINOPRIL-HCTZ 10/12.5 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
LISINOPRIL-HCTZ 20-25MG TABLET (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
LISINOPRIL-HCTZ 20/12.5 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | Q:60 /30Days |
LITHIUM CARBONATE 150MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LITHIUM CARBONATE 300MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
Lithium Carbonate 450mg/1 |
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 |
LITHIUM CARBONATE CAPSULES |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LITHIUM CARBONATE ER TABLET 300MG (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LITHIUM CIT 8MEQ/5ML SYRUP |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LOPERAMIDE HCL 2MG CAPSULE |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LOSARTAN POTASSIUM 100 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 25 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN POTASSIUM 50 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-12.5 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN-HCTZ 100-25 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LOSARTAN-HCTZ 50-12.5 MG TAB |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LOTEMAX 0.5% EYE DROPS |
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 |
LOTREL 10/20MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LOTREL 10/40MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LOTREL 2.5/10MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
Lotrel 5; 40mg/1; mg/1 100 CAPSULE in 1 BOTTLE |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LOTREL 5/10MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LOTREL 5/20MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LOTRONEX TABLETS .5MG 30 BOTPL |
2 |
Tier 2 |
$20.00 | $40.00 | Q:60 /30Days |
LOTRONEX TABLETS 1MG 30 BOTPL |
2 |
Tier 2 |
$20.00 | $40.00 | Q:60 /30Days |
Lovastatin 10mg 60 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
Lovastatin 20mg 500 TABLET BOTTLE |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days |
LOVASTATIN 40 MG ORAL TABLET |
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 |
LOVAZA 1g/ 120 LIQUID FILLED CAPSULES in BOTTLE |
2 |
Tier 2 |
$20.00 | $40.00 | None |
LOVENOX 100MG PREFILLED SYR |
3 |
Tier 3 |
$60.00 | $120.00 | Q:28 /14Days |
LOVENOX 120MG PREFILLED SYR |
3 |
Tier 3 |
$60.00 | $120.00 | Q:28 /14Days |
LOVENOX 150MG PREFILLED SYR |
3 |
Tier 3 |
$60.00 | $120.00 | Q:28 /14Days |
LOVENOX 300MG VIAL |
3 |
Tier 3 |
$60.00 | $120.00 | Q:28 /14Days |
LOVENOX 30MG PREFILLED SYRN |
3 |
Tier 3 |
$60.00 | $120.00 | Q:28 /14Days |
LOVENOX 40MG PREFILLED SYRN |
3 |
Tier 3 |
$60.00 | $120.00 | Q:28 /14Days |
LOVENOX 60MG PREFILLED SYRN |
3 |
Tier 3 |
$60.00 | $120.00 | Q:28 /14Days |
LOVENOX 80MG PREFILLED SYRN |
3 |
Tier 3 |
$60.00 | $120.00 | Q:28 /14Days |
LOXAPINE 25MG CAPSULE (100 CT) |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LOXAPINE CAPSULES 10MG 100 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 |
LOXAPINE CAPSULES 50MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LOXAPINE CAPSULES 5MG 100 BOT |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LUFYLLIN 200MG TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LUFYLLIN-400 TABLET |
1 |
Tier 1 |
$0.00 | $0.00 | None |
LUMIGAN 0.03% EYE DROPS |
3 |
Tier 3 |
$60.00 | $120.00 | Q:3 /25Days |
LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER in 1 CARTON / 5 mL in 1 BOTTLE, DROPPER |
3 |
Tier 3 |
$60.00 | $120.00 | Q:3 /25Days |
LUNESTA 2MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LUNESTA 3MG TABLET |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LUNESTA TABLETS 1MG 30 BOT |
3 |
Tier 3 |
$60.00 | $120.00 | Q:30 /30Days |
LUPRON DEPOT 3.75 MG KIT |
3 |
Tier 3 |
$60.00 | $120.00 | P |
LYRICA 100MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | P Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
LYRICA 150MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | P Q:90 /30Days |
LYRICA 200MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | P Q:90 /30Days |
LYRICA 225MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | P Q:90 /30Days |
LYRICA 25MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | P Q:90 /30Days |
LYRICA 300MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | P Q:90 /30Days |
LYRICA 50MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | P Q:90 /30Days |
LYRICA 75MG CAPSULE |
3 |
Tier 3 |
$60.00 | $120.00 | P Q:90 /30Days |
LYSODREN 500MG TABLET |
2 |
Tier 2 |
$20.00 | $40.00 | None |