2016 Medicare Part D Plan Formulary Information |
Medicare Plus Blue PPO Assure (PPO) (H9572-003-3)
Benefit Details
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The Medicare Plus Blue PPO Assure (PPO) (H9572-003-3) Formulary Drugs Starting with the Letter O in Saginaw County, MI: CMS MA Region 11 which includes: MI Plan Monthly Premium: $294.00 Deductible: $0 |
Drugs Starting with Letter O
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
OCELLA 3MG/0.03MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OCELLA 3MG/0.03MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OCTAGAM 10% VIAL ![Compare how all Medicare Part D PDP plans in MI cover OCTAGAM 10% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | P |
OCTAGAM 5% VIAL ![Compare how all Medicare Part D PDP plans in MI cover OCTAGAM 5% VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | P |
OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD ![Compare how all Medicare Part D PDP plans in MI cover OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP ![Compare how all Medicare Part D PDP plans in MI cover OCTREOTIDE ACETATE INJECTION 100MCG 10 X1ML AMP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP ![Compare how all Medicare Part D PDP plans in MI cover OCTREOTIDE ACETATE INJECTION 500MCG 10 X1ML AMP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD ![Compare how all Medicare Part D PDP plans in MI cover OCTREOTIDE ACETATE INJECTION SOLUTION 200MCG 1 X 5ML VIALMD.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP ![Compare how all Medicare Part D PDP plans in MI cover OCTREOTIDE ACETATE INJECTION SOLUTION 50MCG 10X1ML AMP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT ![Compare how all Medicare Part D PDP plans in MI cover OCUTRICIN EYE OINTMENT 400UNT/3.5MG/10UNT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
ODEFSEY TABLET ![Compare how all Medicare Part D PDP plans in MI cover ODEFSEY TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ODOMZO 200 MG CAPSULE ![Compare how all Medicare Part D PDP plans in MI cover ODOMZO 200 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
OFEV 100 MG CAPSULE ![Compare how all Medicare Part D PDP plans in MI cover OFEV 100 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
OFEV 150 MG CAPSULE ![Compare how all Medicare Part D PDP plans in MI cover OFEV 150 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
OFLOXACIN 0.3 % DRP ![Compare how all Medicare Part D PDP plans in MI cover OFLOXACIN 0.3 % DRP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OFLOXACIN 0.3% EAR DROPS ![Compare how all Medicare Part D PDP plans in MI cover OFLOXACIN 0.3% EAR DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OFLOXACIN 400MG TABLET (100 CT) ![Compare how all Medicare Part D PDP plans in MI cover OFLOXACIN 400MG TABLET (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE 10 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE 10 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE 10 MG VIAL [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE 10 MG VIAL [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE 15 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE 15 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE 2.5 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE 2.5 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE 20 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE 20 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLANZAPINE 5 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE 5 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE 7.5 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE 7.5 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE ODT 10 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE ODT 10 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE ODT 15 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE ODT 15 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE ODT 20 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE ODT 20 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE ODT 5 MG TABLET [Zyprexa] ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE ODT 5 MG TABLET [Zyprexa].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE-FLUOXETINE 12-25 MG ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE-FLUOXETINE 12-25 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE-FLUOXETINE 12-50 MG ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE-FLUOXETINE 12-50 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
olanzapine-fluoxetine 3-25 mg ![Compare how all Medicare Part D PDP plans in MI cover olanzapine-fluoxetine 3-25 mg.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE-FLUOXETINE 6-25 MG ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE-FLUOXETINE 6-25 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLANZAPINE-FLUOXETINE 6-50 MG ![Compare how all Medicare Part D PDP plans in MI cover OLANZAPINE-FLUOXETINE 6-50 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OLOPATADINE 665 MCG NASAL SPRY ![Compare how all Medicare Part D PDP plans in MI cover OLOPATADINE 665 MCG NASAL SPRY.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLOPATADINE HCL 0.1% EYE DROPS ![Compare how all Medicare Part D PDP plans in MI cover OLOPATADINE HCL 0.1% EYE DROPS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OLYSIO 150 MG CAPSULE ![Compare how all Medicare Part D PDP plans in MI cover OLYSIO 150 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza] ![Compare how all Medicare Part D PDP plans in MI cover OMEGA-3 ETHYL ESTERS 1 GM CAPSULE [Lovaza].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT) ![Compare how all Medicare Part D PDP plans in MI cover OMEPRAZOLE 10MG CAPSULE DELAYED RELEASE (30 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE ![Compare how all Medicare Part D PDP plans in MI cover Omeprazole 20mg DELAYED RELEASE 100 CAPSULE BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG ![Compare how all Medicare Part D PDP plans in MI cover OMEPRAZOLE CAPSULES DELAYED RELEASE 40 MG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OMEPRAZOLE-BICARB 20-1,100 CAP ![Compare how all Medicare Part D PDP plans in MI cover OMEPRAZOLE-BICARB 20-1,100 CAP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OMEPRAZOLE-BICARB 40-1,100 CAP ![Compare how all Medicare Part D PDP plans in MI cover OMEPRAZOLE-BICARB 40-1,100 CAP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OMNARIS 50MCG SPRAY NON-AEROSOL ![Compare how all Medicare Part D PDP plans in MI cover OMNARIS 50MCG SPRAY NON-AEROSOL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM ![Compare how all Medicare Part D PDP plans in MI cover OMNITROPE FOR INJECTION KIT 5.8MG 1 BOX PKGCOM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG ![Compare how all Medicare Part D PDP plans in MI cover OMNITROPE INJECTION 10MG/1.5ML 10MG X 1.5ML CTG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | P |
OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG ![Compare how all Medicare Part D PDP plans in MI cover OMNITROPE INJECTION 5MG/1.5ML 1.5 ML CTG.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | P |
Oncaspar 750[iU]/mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE ![Compare how all Medicare Part D PDP plans in MI cover Oncaspar 750[iU]/mL 1 VIAL, SINGLE-USE per CARTON / 5 mL in 1 VIAL, SINGLE-USE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
Ondansetron 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL ![Compare how all Medicare Part D PDP plans in MI cover Ondansetron 2mg/mL 25 VIAL in 1 CARTON / 2 mL in 1 VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
ONDANSETRON 4 MG/2 ML ISECURE ![Compare how all Medicare Part D PDP plans in MI cover ONDANSETRON 4 MG/2 ML ISECURE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
ONDANSETRON HCL 24 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ONDANSETRON HCL 24 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | P |
ONDANSETRON HCL 4MG/5ML SOLUTION ORAL ![Compare how all Medicare Part D PDP plans in MI cover ONDANSETRON HCL 4MG/5ML SOLUTION ORAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | P |
ONDANSETRON HCL 8 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ONDANSETRON HCL 8 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | P |
Ondansetron Hydrochloride 4mg/1 ![Compare how all Medicare Part D PDP plans in MI cover Ondansetron Hydrochloride 4mg/1.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | P |
ONDANSETRON ODT 4MG TABLET (30 CT) ![Compare how all Medicare Part D PDP plans in MI cover ONDANSETRON ODT 4MG TABLET (30 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | P |
ONDANSETRON ODT 8MG (10 CT) ![Compare how all Medicare Part D PDP plans in MI cover ONDANSETRON ODT 8MG (10 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ONFI 10 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ONFI 10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:180 /90Days |
ONFI 2.5 MG/ML SUSPENSION ![Compare how all Medicare Part D PDP plans in MI cover ONFI 2.5 MG/ML SUSPENSION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:1440 /90Days |
ONFI 20 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ONFI 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:180 /90Days |
ONGLYZA 2.5 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ONGLYZA 2.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /90Days |
ONGLYZA 5 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ONGLYZA 5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:90 /90Days |
OPANA ER 10 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OPANA ER 10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:180 /90Days |
OPANA ER 15 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OPANA ER 15 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:180 /90Days |
OPANA ER 20 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OPANA ER 20 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:180 /90Days |
OPANA ER 30 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OPANA ER 30 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:180 /90Days |
OPANA ER 40 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OPANA ER 40 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:180 /90Days |
OPANA ER 5 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OPANA ER 5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:180 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OPANA ER 7.5 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OPANA ER 7.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:180 /90Days |
OPDIVO 40 MG/4 ML VIAL ![Compare how all Medicare Part D PDP plans in MI cover OPDIVO 40 MG/4 ML VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
OPSUMIT 10 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OPSUMIT 10 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
ORAP 1MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ORAP 1MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
ORAP 2MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ORAP 2MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
3 |
Preferred Brand |
$40.00 | $100.00 | None |
ORAVIG 50 MG BUCCAL TABLET ![Compare how all Medicare Part D PDP plans in MI cover ORAVIG 50 MG BUCCAL TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | Q:90 /90Days |
ORENCIA 125 MG/ML SYRINGE ![Compare how all Medicare Part D PDP plans in MI cover ORENCIA 125 MG/ML SYRINGE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
ORENITRAM ER 0.125 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ORENITRAM ER 0.125 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | P |
ORENITRAM ER 0.25 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ORENITRAM ER 0.25 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
ORENITRAM ER 1 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ORENITRAM ER 1 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
ORENITRAM ER 2.5 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ORENITRAM ER 2.5 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
ORFADIN 10 MG CAPSULE ![Compare how all Medicare Part D PDP plans in MI cover ORFADIN 10 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
ORFADIN 2 MG CAPSULE ![Compare how all Medicare Part D PDP plans in MI cover ORFADIN 2 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
ORFADIN 4 MG/ML SUSPENSION ![Compare how all Medicare Part D PDP plans in MI cover ORFADIN 4 MG/ML SUSPENSION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
ORFADIN 5 MG CAPSULE ![Compare how all Medicare Part D PDP plans in MI cover ORFADIN 5 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
ORKAMBI 200 MG-125 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover ORKAMBI 200 MG-125 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
ORTHO TRI CYCLEN Lo 6 DIALPACK per CARTON / 1 KIT in 1 DIALPACK ![Compare how all Medicare Part D PDP plans in MI cover ORTHO TRI CYCLEN Lo 6 DIALPACK per CARTON / 1 KIT in 1 DIALPACK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OSMOPREP TABLET 1.5GM ![Compare how all Medicare Part D PDP plans in MI cover OSMOPREP TABLET 1.5GM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OTEZLA 28 DAY STARTER PACK ![Compare how all Medicare Part D PDP plans in MI cover OTEZLA 28 DAY STARTER PACK.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
OTEZLA 30 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OTEZLA 30 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | P |
OTREXUP 10 MG/0.4 ML AUTO-INJ ![Compare how all Medicare Part D PDP plans in MI cover OTREXUP 10 MG/0.4 ML AUTO-INJ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OTREXUP 15 MG/0.4 ML AUTO-INJ ![Compare how all Medicare Part D PDP plans in MI cover OTREXUP 15 MG/0.4 ML AUTO-INJ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OTREXUP 17.5 MG/0.4 ML AUTOINJ ![Compare how all Medicare Part D PDP plans in MI cover OTREXUP 17.5 MG/0.4 ML AUTOINJ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OTREXUP 20 MG/0.4 ML AUTO-INJ ![Compare how all Medicare Part D PDP plans in MI cover OTREXUP 20 MG/0.4 ML AUTO-INJ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OTREXUP 22.5 MG/0.4 ML AUTOINJ ![Compare how all Medicare Part D PDP plans in MI cover OTREXUP 22.5 MG/0.4 ML AUTOINJ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OTREXUP 25 MG/0.4 ML AUTO-INJ ![Compare how all Medicare Part D PDP plans in MI cover OTREXUP 25 MG/0.4 ML AUTO-INJ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OTREXUP 7.5 MG/0.4 ML AUTO-INJ ![Compare how all Medicare Part D PDP plans in MI cover OTREXUP 7.5 MG/0.4 ML AUTO-INJ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OXACILLIN 10 GM VIAL ![Compare how all Medicare Part D PDP plans in MI cover OXACILLIN 10 GM VIAL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXACILLIN 1GM/50ML INJ ![Compare how all Medicare Part D PDP plans in MI cover OXACILLIN 1GM/50ML INJ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
Oxacillin 2 gm add-vantage vl ![Compare how all Medicare Part D PDP plans in MI cover Oxacillin 2 gm add-vantage vl.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXACILLIN 2GM/50ML INJ ![Compare how all Medicare Part D PDP plans in MI cover OXACILLIN 2GM/50ML INJ.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION ![Compare how all Medicare Part D PDP plans in MI cover OXALIPLATIN 5 MG/ML INJECTABLE SOLUTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
5 |
Specialty Tier |
33% | N/A | None |
oxandrolone 10mg/1 60 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MI cover oxandrolone 10mg/1 60 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXANDROLONE 2.5MG TABLETS ![Compare how all Medicare Part D PDP plans in MI cover OXANDROLONE 2.5MG TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | P |
OXAPROZIN 600MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OXAPROZIN 600MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXCARBAZEPINE 150MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OXCARBAZEPINE 150MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXCARBAZEPINE 300 MG/5 ML SUSP ![Compare how all Medicare Part D PDP plans in MI cover OXCARBAZEPINE 300 MG/5 ML SUSP.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXCARBAZEPINE 300MG TABLET 500 NCRC BOT ![Compare how all Medicare Part D PDP plans in MI cover OXCARBAZEPINE 300MG TABLET 500 NCRC BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXCARBAZEPINE 600MG TABLET 500 NCRC BOT ![Compare how all Medicare Part D PDP plans in MI cover OXCARBAZEPINE 600MG TABLET 500 NCRC BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXICONAZOLE NITRATE 1% CREAM [Oxistat] ![Compare how all Medicare Part D PDP plans in MI cover OXICONAZOLE NITRATE 1% CREAM [Oxistat].](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXISTAT 1% CREAM ![Compare how all Medicare Part D PDP plans in MI cover OXISTAT 1% CREAM.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OXISTAT 1% LOTION ![Compare how all Medicare Part D PDP plans in MI cover OXISTAT 1% LOTION.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None |
OXTELLAR XR 150 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OXTELLAR XR 150 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | S |
OXTELLAR XR 300 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OXTELLAR XR 300 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | S |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXTELLAR XR 600 MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OXTELLAR XR 600 MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | S |
OXYBUTYNIN 5MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OXYBUTYNIN 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R ![Compare how all Medicare Part D PDP plans in MI cover Oxybutynin Chloride 10mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED R.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:180 /90Days |
Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE ![Compare how all Medicare Part D PDP plans in MI cover Oxybutynin Chloride 5mg/1 100 BLISTER PACK in 1 BOX, UNIT-DOSE / 1 TABLET, FILM COATED, EXTENDED RE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:180 /90Days |
Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in MI cover Oxybutynin Chloride 5mg/5mL 473 mL in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT) ![Compare how all Medicare Part D PDP plans in MI cover OXYBUTYNIN CHLORIDE TABLET ER 15MG (100 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:180 /90Days |
OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT) ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE AND ACETAMINOPHEN 325-5MG TABLET USP (500 CT).](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:1080 /90Days |
OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE AND ACETAMINOPHEN TABLETS 2.5;325MG;MG 100 BOT.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:1080 /90Days |
OXYCODONE HCL 100 MG/5 ML SOLN ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE HCL 100 MG/5 ML SOLN.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:1800 /90Days |
OXYCODONE HCL 30MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE HCL 30MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:540 /90Days |
OXYCODONE HCL 5 MG CAPSULE ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE HCL 5 MG CAPSULE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:1080 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
OXYCODONE HCL 5 MG/5 ML Solution ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE HCL 5 MG/5 ML Solution.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | None |
OXYCODONE HCL 5MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE HCL 5MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:1080 /90Days |
OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE HCL-ACETAMINOPHEN 10MG-325MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:1080 /90Days |
OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:540 /90Days |
OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE HYDROCHLORIDE 20mg/1 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:540 /90Days |
Oxycodone Hydrochloride and Aspirin 325; 4.8355mg 100 TABLET BOTTLE ![Compare how all Medicare Part D PDP plans in MI cover Oxycodone Hydrochloride and Aspirin 325; 4.8355mg 100 TABLET BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:1080 /90Days |
OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE HYDROCHLORIDE TABLETS 15MG 100 TABLETS BOTPL.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:540 /90Days |
Oxycodone-Acetaminophen 5-325/5 ![Compare how all Medicare Part D PDP plans in MI cover Oxycodone-Acetaminophen 5-325/5.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:1891 /31Days |
OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE-ACETAMINOPHEN 7.5-325MG TABLET.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:1080 /90Days |
OXYCODONE-IBUPROFEN 5-400 TAB ![Compare how all Medicare Part D PDP plans in MI cover OXYCODONE-IBUPROFEN 5-400 TAB.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:720 /90Days |
oxymorphone hcl er 10 mg tab ![Compare how all Medicare Part D PDP plans in MI cover oxymorphone hcl er 10 mg tab.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:180 /90Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
oxymorphone hcl er 20 mg tab ![Compare how all Medicare Part D PDP plans in MI cover oxymorphone hcl er 20 mg tab.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:180 /90Days |
oxymorphone hcl er 30 mg tab ![Compare how all Medicare Part D PDP plans in MI cover oxymorphone hcl er 30 mg tab.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:180 /90Days |
oxymorphone hcl er 40 mg tab ![Compare how all Medicare Part D PDP plans in MI cover oxymorphone hcl er 40 mg tab.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:180 /90Days |
oxymorphone hcl er 5 mg tablet ![Compare how all Medicare Part D PDP plans in MI cover oxymorphone hcl er 5 mg tablet.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:180 /90Days |
OXYMORPHONE HYDROCHLORIDE 10MG TABLETS ![Compare how all Medicare Part D PDP plans in MI cover OXYMORPHONE HYDROCHLORIDE 10MG TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:540 /90Days |
Oxymorphone hydrochloride 15mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in MI cover Oxymorphone hydrochloride 15mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:180 /90Days |
OXYMORPHONE HYDROCHLORIDE 5MG TABLETS ![Compare how all Medicare Part D PDP plans in MI cover OXYMORPHONE HYDROCHLORIDE 5MG TABLETS.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:540 /90Days |
Oxymorphone hydrochloride 7.5mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE ![Compare how all Medicare Part D PDP plans in MI cover Oxymorphone hydrochloride 7.5mg/1 100 TABLET, EXTENDED RELEASE in 1 BOTTLE.](https://q1medicare.com/pics/ContentPics/compare_partd_plans_by_drug.png) |
2 |
Generic |
$14.00 | $35.00 | Q:180 /90Days |