2015 Medicare Part D Plan Formulary Information |
Cigna-HealthSpring Rx Secure-Xtra (PDP) (S5617-264-0)
Benefit Details
|
The Cigna-HealthSpring Rx Secure-Xtra (PDP) (S5617-264-0) Formulary Drugs Starting with the Letter N in CMS PDP Region 19 which includes: AR Plan Monthly Premium: $34.10 Deductible: $0 Qualifies for LIS: No |
Drugs Starting with Letter N
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
NABUMETONE 500MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NABUMETONE 750MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NADOLOL 20MG TABLET |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
NADOLOL 40MG TABLETS |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Nadolol 80mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NADOLOL-BENDROFLU 40-5 MG TAB |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NADOLOL-BENDROFLU 80-5 MG TAB |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nafcillin 1 gm vial |
4 |
Non-Preferred Brand |
35% | 35% | None |
Nafcillin 10g/100mL |
4 |
Non-Preferred Brand |
35% | 35% | None |
NAFTIFINE HCL 1% CREAM [Naftin] |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAFTIN 1% CREAM |
3 |
Preferred Brand |
20% | 20% | None |
NAFTIN 2% CREAM |
3 |
Preferred Brand |
20% | 20% | None |
NAFTIN 2% GEL |
3 |
Preferred Brand |
20% | 20% | None |
NAFTIN HCL GEL 1% 60GM TUBE |
3 |
Preferred Brand |
20% | 20% | None |
NAGLAZYME 5MG/5ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Brand |
35% | 35% | None |
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Brand |
35% | 35% | None |
naloxone 1 mg/ml syringe |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NALTREXONE HCL 50MG TABLET 100 BLPK |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | P |
NAMENDA 10MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
NAMENDA 10MG/5ML SOLUTION |
3 |
Preferred Brand |
20% | 20% | Q:300 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMENDA 5-10MG TITRATION PK |
3 |
Preferred Brand |
20% | 20% | Q:49 /28Days |
NAMENDA 5MG TABLET |
3 |
Preferred Brand |
20% | 20% | Q:90 /30Days |
NAMENDA XR 14 MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
NAMENDA XR 21 MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
NAMENDA XR 28 MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
NAMENDA XR 7 MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:30 /30Days |
NAMENDA XR TITRATION PACK |
3 |
Preferred Brand |
20% | 20% | Q:28 /28Days |
NAPROXEN 125 MG/5 ML SUSPEN |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NAPROXEN 250 MG ORAL TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NAPROXEN 375MG TABLET EC |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NAPROXEN 500MG TABLET EC |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Naproxen 500mg/1 500 TABLET BOTTLE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
NAPROXEN SODIUM 275 MG ORAL TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Naproxen Sodium 550mg/1 |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NAPROXEN TABLET 375MG (500 CT) |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
NARATRIPTAN 1MG TABLETS |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:9 /30Days |
NARATRIPTAN 2.5MG TABLETS |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:9 /30Days |
NATACYN EYE DROPS |
3 |
Preferred Brand |
20% | 20% | None |
Nateglinide 120mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:90 /30Days |
Nateglinide 60mg/1 90 TABLET BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:90 /30Days |
NEBUPENT 300MG INHAL POWDER |
3 |
Preferred Brand |
20% | 20% | P |
NECON 0.5/35-28 TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NECON 1/35-28 TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NECON 10/11-28 TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NECON 7-7-7-28 TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:60 /30Days |
NEFAZODONE HCL 250MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:60 /30Days |
NEFAZODONE HCL 50MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:60 /30Days |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:60 /30Days |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:60 /30Days |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Neomycin and Polymyxin B Sulfates 40; 200000mg/mL; 1/mL 10 AMPULE per CARTON / 1 mL in 1 AMPULE |
4 |
Non-Preferred Brand |
35% | 35% | None |
Neomycin and Polymyxin B Sulfates and Dexamethasone 1; 3.5; 10000mg/g; mg/g; [USP'U]/g 1 TUBE in 1 |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYCIN SULFATE 500MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NEOMYCIN/POLYMY/DEXA EYE DROPS 3.5MG/1ML |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NEPHRAMINE SOLUTION FOR INJECTION |
4 |
Non-Preferred Brand |
35% | 35% | P |
NEULASTA 6MG/0.6ML SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
NEUPOGEN 300 MCG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
NEUPOGEN 300MCG/ML VIAL |
5 |
Specialty Tier |
33% | 33% | P |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
5 |
Specialty Tier |
33% | 33% | P |
NEUPRO 1 MG/24 HR PATCH |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
NEUPRO 2 MG/24 HR PATCH |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
NEUPRO 3 MG/24 HR PATCH |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
NEUPRO 4 MG/24 HR PATCH |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
NEUPRO 6 MG/24 HR PATCH |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
NEUPRO 8 MG/24 HR PATCH |
4 |
Non-Preferred Brand |
35% | 35% | P Q:30 /30Days |
nevirapine 200 mg tablet |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NEVIRAPINE 50 MG/5 ML SUSP |
3 |
Preferred Brand |
20% | 20% | None |
nevirapine er 400 mg tablet |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier |
33% | 33% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEXIUM 10mg/1 30 GRANULE, DELAYED RELEASE per CARTON |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
NEXIUM 20MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
NEXIUM 20MG SUSP FOR RECON DELAYED REL. IN A PACKET |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
NEXIUM 40MG CAPSULE |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
NEXIUM 40MG SUSP FOR RECON DELAYED REL. IN A PACKET |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
NEXIUM DR 2.5 MG PACKET |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
NEXIUM DR 5 MG PACKET |
3 |
Preferred Brand |
20% | 20% | Q:60 /30Days |
NIACIN ER 1,000 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:60 /30Days |
NIACIN ER 500 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:30 /30Days |
NIACIN ER 750 MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:60 /30Days |
NIACOR 500MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nicardipine 25 mg/10 ml vial |
4 |
Non-Preferred Brand |
35% | 35% | None |
NICARDIPINE HYDROCHLORIDE 20MG CAPSULES |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NICARDIPINE HYDROCHLORIDE CAPSULES 30MG 500 BOT |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NICOTROL INHALER 10MG 168 X 10MG/CARTRIDGE INHL |
3 |
Preferred Brand |
20% | 20% | P Q:504 /30Days |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
3 |
Preferred Brand |
20% | 20% | P Q:40 /30Days |
NIFEDICAL XL 30MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NIFEDICAL XL 60MG TABLET SR OSMOTIC PUSH 24HR |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NIFEDIPINE 30MG TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NIFEDIPINE 60MG TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NIFEDIPINE 90MG TABLETS EXTENDED RELEASE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NILANDRON 150 MG TABLET |
5 |
Specialty Tier |
33% | 33% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nimodipine 30mg/1 25 BLISTER PACK in 1 CARTON / 4 CAPSULE in 1 BLISTER PACK |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NIPENT FOR INJECTION 10MG VIALS |
5 |
Specialty Tier |
33% | 33% | P |
Nisoldipine 17mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NISOLDIPINE 20MG TB24 |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nisoldipine 25.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NISOLDIPINE 30MG TB24 |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nisoldipine 34mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NISOLDIPINE 40MG TB24 |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nisoldipine 8.5mg/1 100 TABLET, FILM COATED, EXTENDED RELEASE in 1 BOTTLE, PLASTIC |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nitrofurantoin 25mg/5mL |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:900 /365Days |
Nitrofurantoin Macrocrystals 50mg/1 100 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:90 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nitrofurantoin mcr 100 mg cap |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:90 /365Days |
Nitrofurantoin Monohydrate/Macrocrystals 25; 75mg 100 CAPSULE BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | Q:90 /365Days |
NITROGLYCERIN .2MG/HR PATCH |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NITROGLYCERIN .4MG/HR PATCH |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NITROGLYCERIN .6MG/HR PATCH |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Brand |
35% | 35% | None |
NITROGLYCERIN LINGUAL 0.4 MG |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NITROSTAT 0.3MG TABLET SL |
3 |
Preferred Brand |
20% | 20% | None |
NITROSTAT 0.4MG TABLET SL |
3 |
Preferred Brand |
20% | 20% | None |
NITROSTAT 0.6MG TABLET SL |
3 |
Preferred Brand |
20% | 20% | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nizatidine 150mg/1 60 CAPSULE in 1 BOTTLE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NIZATIDINE 300 MG CAPSULE (100 CAPS) |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Norethindrone 0.35 mg tablet |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NORETHINDRONE 5MG TABLET |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NORITATE 1% CREAM |
3 |
Preferred Brand |
20% | 20% | None |
Norlyroc 0.35 mg tablet |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NORMOSOL -R INJ /D5W |
4 |
Non-Preferred Brand |
35% | 35% | P |
NORMOSOL-M AND DEXTROSE 5% |
4 |
Non-Preferred Brand |
35% | 35% | P |
NORMOSOL-R PH 7.4 IV SOLUTION |
4 |
Non-Preferred Brand |
35% | 35% | P |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTREL 1-0.035MG TABLET 28DAY |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NORTRIPTYLINE 10 MG/5 ML SOL |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NORTRIPTYLINE HCL 25MG CAP |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
NORTRIPTYLINE HCL 75MG CAPSULE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
Nortriptyline Hydrochloride 50mg/1 500 CAPSULE BOTTLE |
1 |
Preferred Generic |
$1.00 | $3.00 | None |
NORVIR 100 MG TABLET |
3 |
Preferred Brand |
20% | 20% | None |
NORVIR 100mg/1 30 CAPSULE BOTTLE |
3 |
Preferred Brand |
20% | 20% | None |
NORVIR 80MG/ML ORAL SOLUTION |
3 |
Preferred Brand |
20% | 20% | None |
novarel 10,000 units vial |
4 |
Non-Preferred Brand |
35% | 35% | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier |
33% | 33% | P Q:600 /30Days |
NOXAFIL DR 100 MG TABLET |
5 |
Specialty Tier |
33% | 33% | P Q:93 /30Days |
NUEDEXTA 20; 10mg/1; mg/1 |
3 |
Preferred Brand |
20% | 20% | P |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
5 |
Specialty Tier |
33% | 33% | P |
NUTRILIPID 20 % EMULSION |
4 |
Non-Preferred Brand |
35% | 35% | P |
NUTRILIPID 20% IV FAT EMULSION |
4 |
Non-Preferred Brand |
35% | 35% | P |
NYAMYC 100000 U/G POWDER |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nystatin 100000[USP'U]/g |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Nystatin 100000[USP'U]/mL |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NYSTATIN TABLET 500000U (100 CT) |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NYSTATIN/TRIAMCINOLONE CRM |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |
NYSTOP 100000U/GM POWDER |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None |