2014 Medicare Part D Plan Formulary Information |
Cigna-HealthSpring Rx -Reg 15 (PDP) (S5932-014-0)
Benefit Details
|
The Cigna-HealthSpring Rx -Reg 15 (PDP) (S5932-014-0) Formulary Drugs Starting with the Letter M in CMS PDP Region 15 which includes: IN KY Plan Monthly Premium: $35.50 Deductible: $310 Qualifies for LIS: Yes |
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 |
1 |
On Formulary |
25% | 25% | None |
MAGNESIUM SULFATE INJECTION 5 GM/10ML |
1 |
On Formulary |
25% | 25% | P |
Malathion 5mg/mL 1 BOTTLE per CARTON / 59 mL in 1 BOTTLE |
1 |
On Formulary |
25% | 25% | None |
MAPROTILINE 25MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MAPROTILINE 50MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MAPROTILINE 75MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MARLISSA-28 TABLET |
1 |
On Formulary |
25% | 25% | None |
MARPLAN 10MG TABLET (100 CT) |
1 |
On Formulary |
25% | 25% | None |
MATULANE 50MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
Matzim LA 240mg/1 90 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
1 |
On Formulary |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MECLIZINE HYDROCHLORIDE TABLETS 12.5MG 100 BOT |
1 |
On Formulary |
25% | 25% | None |
MECLIZINE HYDROCHLORIDE TABLETS 25MG 100 BOT |
1 |
On Formulary |
25% | 25% | None |
MECLOFENAMATE 100MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
MECLOFENAMATE 50MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
Medroxyprogesterone Acetate 10mg/1 500 TABLET BOTTLE |
1 |
On Formulary |
25% | 25% | None |
Medroxyprogesterone Acetate 2.5mg/1 500 TABLET BOTTLE |
1 |
On Formulary |
25% | 25% | None |
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE |
1 |
On Formulary |
25% | 25% | None |
MEDROXYPROGESTERONE ACETATE INJECTION SUSPENSION 150MG 1 VIALSD CRTN |
1 |
On Formulary |
25% | 25% | Q:1 /90Days |
MEFLOQUINE HCL 250MG TABLET 25 BOT |
1 |
On Formulary |
25% | 25% | None |
MEGESTROL 20MG TABLET |
1 |
On Formulary |
25% | 25% | P |
MEGESTROL ACETATE 40MG TABLET (250 CT) |
1 |
On Formulary |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Megestrol Acetate 40mg/mL 480 mL in 1 BOTTLE, PLASTIC |
1 |
On Formulary |
25% | 25% | P |
MEKINIST 0.5 MG TABLET |
1 |
On Formulary |
25% | 25% | P |
MEKINIST 2 MG TABLET |
1 |
On Formulary |
25% | 25% | P |
MELOXICAM 15 MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MELOXICAM 7.5 MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MELPHALAN 5 MG/ML INJECTABLE SOLUTION |
1 |
On Formulary |
25% | 25% | P |
Menactra 4; 4; 4; 4ug/0.5mL; ug/0.5mL; ug/0.5mL; ug/0.5mL 5 VIAL, SINGLE-DOSE in 1 PACKAGE / 0.5 mL |
1 |
On Formulary |
25% | 25% | None |
MENEST 0.3MG TABLET |
1 |
On Formulary |
25% | 25% | P |
MENEST 0.625MG TABLET |
1 |
On Formulary |
25% | 25% | P |
MENEST 1.25MG TABLET |
1 |
On Formulary |
25% | 25% | P |
MENEST 2.5MG TABLET |
1 |
On Formulary |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MENOMUNE-A/C/Y/W-135 VIAL |
1 |
On Formulary |
25% | 25% | None |
MENOSTAR 14 MCG/DAY PATCH |
1 |
On Formulary |
25% | 25% | P |
MENVEO INJECTION KIT |
1 |
On Formulary |
25% | 25% | None |
MEPRON 750MG/5ML ORAL SUSP |
1 |
On Formulary |
25% | 25% | None |
MERCAPTOPURINE 50MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MEROPENEM 500MG/VIAL FOR INJECTION |
1 |
On Formulary |
25% | 25% | None |
Mesalamine 1 KIT per CARTON |
1 |
On Formulary |
25% | 25% | None |
MESNA 100 MG/ML VIAL |
1 |
On Formulary |
25% | 25% | P |
MESNEX 400MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MESTINON 180MG TIMESPAN |
1 |
On Formulary |
25% | 25% | None |
METADATE ER 20MG TABLET SA |
1 |
On Formulary |
25% | 25% | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METAPROTERENOL 10MG TABLET |
1 |
On Formulary |
25% | 25% | None |
METAPROTERENOL 20MG TABLET |
1 |
On Formulary |
25% | 25% | None |
Metaproterenol Sulfate 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC |
1 |
On Formulary |
25% | 25% | None |
METFORMIN HCL 1000MG TABLET (500 CT) |
1 |
On Formulary |
25% | 25% | None |
METFORMIN HCL 500MG TABLET (1000 CT) |
1 |
On Formulary |
25% | 25% | None |
METFORMIN HCL ER 500MG TABLET SR 24HR |
1 |
On Formulary |
25% | 25% | None |
Metformin Hydrochloride 750mg/1 |
1 |
On Formulary |
25% | 25% | None |
METFORMIN HYDROCHLORIDE 850mg/1 100 TABLET BOTTLE |
1 |
On Formulary |
25% | 25% | None |
METHADONE HCL 5MG TABLET (100 CT) |
1 |
On Formulary |
25% | 25% | Q:360 /30Days |
METHADONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE |
1 |
On Formulary |
25% | 25% | Q:360 /30Days |
Methadone Hydrochloride 10mg/5mL |
1 |
On Formulary |
25% | 25% | Q:2000 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methadone Hydrochloride 5mg/5mL |
1 |
On Formulary |
25% | 25% | Q:4000 /30Days |
METHADONE HYDROCHLORIDE INJECTION 10MG/ML |
1 |
On Formulary |
25% | 25% | P |
METHAZOLAMIDE 25MG TABLET |
1 |
On Formulary |
25% | 25% | None |
METHAZOLAMIDE 50MG TABLET |
1 |
On Formulary |
25% | 25% | None |
Methenamine Hippurate 1g/1 |
1 |
On Formulary |
25% | 25% | None |
METHIMAZOLE 10 MG TABLET |
1 |
On Formulary |
25% | 25% | None |
METHIMAZOLE 5MG TABLETS |
1 |
On Formulary |
25% | 25% | None |
methotrexate 1 gm vial |
1 |
On Formulary |
25% | 25% | None |
METHOTREXATE 2.5MG TABLET |
1 |
On Formulary |
25% | 25% | None |
methotrexate 25 mg/ml vial |
1 |
On Formulary |
25% | 25% | None |
METHSCOPOLAMINE BROMIDE 2.5MG TABLET |
1 |
On Formulary |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METHSCOPOLAMINE BROMIDE 5 MG TAB |
1 |
On Formulary |
25% | 25% | None |
METHYLDOPATE 250MG/5ML VIAL |
1 |
On Formulary |
25% | 25% | P |
METHYLPHENIDATE 10MG TABLET |
1 |
On Formulary |
25% | 25% | Q:90 /30Days |
METHYLPHENIDATE 20MG TABLET |
1 |
On Formulary |
25% | 25% | Q:90 /30Days |
METHYLPHENIDATE HYDROCHLORIDE 5mg/1 100 TABLET BOTTLE |
1 |
On Formulary |
25% | 25% | Q:90 /30Days |
METHYLPHENIDATE HYDROCHLORIDE EXTENDED-RELEASE 20mg/1 100 TABLET BOTTLE |
1 |
On Formulary |
25% | 25% | Q:90 /30Days |
methylprednisolone 125 mg vial |
1 |
On Formulary |
25% | 25% | None |
METHYLPREDNISOLONE 16MG TABLET |
1 |
On Formulary |
25% | 25% | None |
METHYLPREDNISOLONE 32MG TABLET |
1 |
On Formulary |
25% | 25% | None |
methylprednisolone 40 mg vial |
1 |
On Formulary |
25% | 25% | None |
Methylprednisolone 40mg/mL 1 VIAL, MULTI-DOSE per CARTON / 5 mL in 1 VIAL, MULTI-DOSE |
1 |
On Formulary |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Methylprednisolone 4mg/1 100 TABLET BOTTLE |
1 |
On Formulary |
25% | 25% | None |
METHYLPREDNISOLONE 8 MG ORAL TABLET |
1 |
On Formulary |
25% | 25% | None |
Methylprednisolone acetate 80mg/mL 25 VIAL, GLASS per CARTON / 1 mL in 1 VIAL, GLASS |
1 |
On Formulary |
25% | 25% | None |
METHYLPREDNISOLONE TABLET 4MG 21 PKGCOM |
1 |
On Formulary |
25% | 25% | None |
METIPRANOLOL 0.3% EYE DROPS |
1 |
On Formulary |
25% | 25% | None |
Metoclopramide 10mg/1 500 TABLET BOTTLE |
1 |
On Formulary |
25% | 25% | None |
METOCLOPRAMIDE 5 MG TABLET |
1 |
On Formulary |
25% | 25% | None |
Metoclopramide 5mg/mL 25 VIAL in 1 TRAY / 2 mL in 1 VIAL |
1 |
On Formulary |
25% | 25% | None |
METOCLOPRAMIDE SOLUTION ORAL USP 5MG 1 PT BOT |
1 |
On Formulary |
25% | 25% | None |
METOLAZONE 10MG TABLET |
1 |
On Formulary |
25% | 25% | None |
METOLAZONE 2.5MG TABLET |
1 |
On Formulary |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOLAZONE 5MG TABLET |
1 |
On Formulary |
25% | 25% | None |
METOPROLOL SUCC ER 100 MG TAB |
1 |
On Formulary |
25% | 25% | None |
METOPROLOL SUCC ER 50 MG TAB |
1 |
On Formulary |
25% | 25% | None |
METOPROLOL SUCCINATE ER 200 MG TAB |
1 |
On Formulary |
25% | 25% | None |
METOPROLOL SUCCINATE ER 25 MG TAB |
1 |
On Formulary |
25% | 25% | None |
METOPROLOL TARTRATE 25MG TABLET (100 CT) |
1 |
On Formulary |
25% | 25% | None |
METOPROLOL TARTRATE INJECTION USP 5MG 10X5ML VIALSD |
1 |
On Formulary |
25% | 25% | None |
METOPROLOL TARTRATE TABLET FILM COATED 50MG (1000 CT) |
1 |
On Formulary |
25% | 25% | None |
METOPROLOL TARTRATE TABLET USP 100MG (1000 CT) |
1 |
On Formulary |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100-50MG TABLET |
1 |
On Formulary |
25% | 25% | None |
METOPROLOL-HYDROCHLOROTHIAZIDE 100MG-25MG TABLET |
1 |
On Formulary |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
METOPROLOL-HYDROCHLOROTHIAZIDE 50MG-25MG TABLET |
1 |
On Formulary |
25% | 25% | None |
METRONIDAZOLE 0.75% CREAM |
1 |
On Formulary |
25% | 25% | None |
METRONIDAZOLE 0.75% LOTION |
1 |
On Formulary |
25% | 25% | None |
Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG |
1 |
On Formulary |
25% | 25% | None |
METRONIDAZOLE TABLETS USP 250MG 250 BOTPL |
1 |
On Formulary |
25% | 25% | None |
METRONIDAZOLE TABLETS USP 500MG 100 BOTPL |
1 |
On Formulary |
25% | 25% | None |
metronidazole topical 1% gel |
1 |
On Formulary |
25% | 25% | None |
METRONIDAZOLE TOPICAL GEL 0.75% 45GM TUBE |
1 |
On Formulary |
25% | 25% | None |
METRONIDAZOLE VAGINAL GEL |
1 |
On Formulary |
25% | 25% | None |
MEXILETINE 150MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
MEXILETINE 200MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MEXILETINE 250MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
MIACALCIN 200IU/ML VIAL |
1 |
On Formulary |
25% | 25% | None |
MICROGESTIN 1-0.02MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MICROGESTIN 1.5-0.03MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MICROGESTIN FE 1.5/30 TABLET |
1 |
On Formulary |
25% | 25% | None |
MICROGESTIN FE 1/20 TABLET |
1 |
On Formulary |
25% | 25% | None |
MIDODRINE HCL 10MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MIDODRINE HCL 2.5MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MIDODRINE HCL 5MG TABLET (100 CT) |
1 |
On Formulary |
25% | 25% | None |
MIGERGOT 2-100MG SUPPOSITORY RECTAL |
1 |
On Formulary |
25% | 25% | None |
MINITRAN 0.1 MG/HR PATCH |
1 |
On Formulary |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MINITRAN 0.2 MG/HR PATCH |
1 |
On Formulary |
25% | 25% | None |
MINITRAN 0.4 MG/HR PATCH |
1 |
On Formulary |
25% | 25% | None |
MINITRAN 0.6 MG/HR PATCH |
1 |
On Formulary |
25% | 25% | None |
MINOCYCLINE 100 MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
MINOCYCLINE 50MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
MINOCYCLINE HCL 75MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
Minocycline Hydrochloride 100mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
On Formulary |
25% | 25% | None |
Minocycline Hydrochloride 75mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
On Formulary |
25% | 25% | None |
MINOCYCLINE HYDROCHLORIDE TABLETS 50MG |
1 |
On Formulary |
25% | 25% | None |
MINOXIDIL 10MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MINOXIDIL 2.5MG TABLET |
1 |
On Formulary |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MIRTAZAPINE 15 MG TABLET |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
MIRTAZAPINE 15MG TABLET RAPID DISSOLVE |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
MIRTAZAPINE 30MG TABLET RAPID DISSOLVE |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
Mirtazapine 45mg/1 500 FILM COATED TABLETS in BOTTLE |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
Mirtazapine 7.5mg/1 |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
MIRTAZAPINE ORALLY DISINTEGRATING TABLETS 45MG 10 X 3 BOX |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
MIRTAZAPINE TABLET 30MG (30 CT) |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
misoprostol 100 mcg tablet |
1 |
On Formulary |
25% | 25% | None |
misoprostol 200 mcg tablet |
1 |
On Formulary |
25% | 25% | None |
MITOMYCIN 20 MG VIAL |
1 |
On Formulary |
25% | 25% | P |
MITOXANTRONE INJECTION 2MG 125ML VIAL |
1 |
On Formulary |
25% | 25% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MODAFINIL 100 MG TABLET [Provigil] |
1 |
On Formulary |
25% | 25% | P Q:30 /30Days |
Moderiba 200 mg tablet |
1 |
On Formulary |
25% | 25% | P |
Moderiba 400-400 mg dosepack |
1 |
On Formulary |
25% | 25% | P |
Moderiba 600-600 mg dosepack |
1 |
On Formulary |
25% | 25% | P |
MOEXIPRIL HCL 15 MG TABLET |
1 |
On Formulary |
25% | 25% | None |
Moexipril HCL 7.5mg/1 100 FILM COATED TABLETS in BOTTLE |
1 |
On Formulary |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-12.5MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 15-25MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MOEXIPRIL-HYDROCHLOROTHIAZIDE 7.5-12.5MG TABLET |
1 |
On Formulary |
25% | 25% | None |
MOMETASONE FUROATE 0.1% OINT |
1 |
On Formulary |
25% | 25% | None |
MOMETASONE FUROATE 0.1% SOLN |
1 |
On Formulary |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Mometasone Furoate 1mg/g 45 g in 1 TUBE |
1 |
On Formulary |
25% | 25% | None |
MONTELUKAST SOD 10 MG TABLET [Singulair] |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
montelukast sod 4 mg granules [Singulair] |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
montelukast sod 4 mg tab chew [Singulair] |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
montelukast sod 5 mg tab chew [Singulair] |
1 |
On Formulary |
25% | 25% | Q:30 /30Days |
MORPHINE SULFATE 100MG TABLET SA |
1 |
On Formulary |
25% | 25% | Q:90 /30Days |
Morphine Sulfate 100mg/5mL 15 mL in 1 BOTTLE |
1 |
On Formulary |
25% | 25% | Q:540 /30Days |
MORPHINE SULFATE 10MG/5ML ORAL SOLUTION |
1 |
On Formulary |
25% | 25% | Q:5400 /30Days |
MORPHINE SULFATE 15MG TABLET SA |
1 |
On Formulary |
25% | 25% | Q:90 /30Days |
MORPHINE SULFATE 15MG TABLETS |
1 |
On Formulary |
25% | 25% | Q:360 /30Days |
MORPHINE SULFATE 200MG TABLET SA |
1 |
On Formulary |
25% | 25% | Q:90 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MORPHINE SULFATE 20MG/5ML ORAL SOLUTION |
1 |
On Formulary |
25% | 25% | Q:2700 /30Days |
MORPHINE SULFATE 30MG TABLET SA |
1 |
On Formulary |
25% | 25% | Q:90 /30Days |
MORPHINE SULFATE 30MG TABLETS |
1 |
On Formulary |
25% | 25% | Q:360 /30Days |
MORPHINE SULFATE TABLET ER 60MG (100 CT) |
1 |
On Formulary |
25% | 25% | Q:90 /30Days |
MOVIPREP 7.5-2.691G POWDER IN PACKET |
1 |
On Formulary |
25% | 25% | None |
MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE |
1 |
On Formulary |
25% | 25% | None |
MOXIFLOXACIN HCL 400 MG TABLET [Avelox] |
1 |
On Formulary |
25% | 25% | None |
MOZOBIL 20 MG/ML VIAL |
1 |
On Formulary |
25% | 25% | P Q:10 /30Days |
Multaq 400mg/1 60 FILM COATED TABLETS in BOTTLE |
1 |
On Formulary |
25% | 25% | Q:60 /30Days |
mupirocin 2% cream |
1 |
On Formulary |
25% | 25% | None |
MUPIROCIN 2% OINTMENT |
1 |
On Formulary |
25% | 25% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
MUSTARGEN 10 MG VIAL |
1 |
On Formulary |
25% | 25% | P |
MYCOBUTIN 150MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
Mycophenolate Mofetil 250mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 CAPSULE per BLISTER PACK |
1 |
On Formulary |
25% | 25% | P |
MYCOPHENOLATE MOFETIL TABLETS 500MG 500 BOT |
1 |
On Formulary |
25% | 25% | P |
Mycophenolic Acid DR 180 mg tb |
1 |
On Formulary |
25% | 25% | P |
Mycophenolic Acid DR 360 mg tb |
1 |
On Formulary |
25% | 25% | P |
MYORISAN 10 MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
MYORISAN 20 MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |
MYORISAN 40 MG CAPSULE |
1 |
On Formulary |
25% | 25% | None |