2018 Medicare Part D Plan Formulary Information |
Anthem MediBlue Dual Advantage (HMO SNP) (H3655-033-0)
Benefit Details
|
The Anthem MediBlue Dual Advantage (HMO SNP) (H3655-033-0) Formulary Drugs Starting with the Letter N in Erie County, OH: CMS MA Region 12 which includes: OH Plan Monthly Premium: $32.00 Deductible: $405 |
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 500 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NABUMETONE 750 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NADOLOL 20 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
NADOLOL 40MG TABLETS |
3 |
Preferred Brand |
$47.00 | N/A | None |
NADOLOL 80 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NADOLOL-BENDROFLU 40-5 MG TAB |
3 |
Preferred Brand |
$47.00 | N/A | None |
NADOLOL-BENDROFLU 80-5 MG TAB |
3 |
Preferred Brand |
$47.00 | N/A | None |
Nafcillin 1 gm vial |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NAFCILLIN 10 GM BULK VIAL |
5 |
Specialty Tier |
25% | N/A | None |
NAGLAZYME 5MG/5ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nalbuphine Hydrochloride 10mg/mL 1 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:180 /30Days |
Nalbuphine Hydrochloride 20mg/mL 25 VIAL, MULTI-DOSE per CARTON / 10 mL in 1 VIAL, MULTI-DOSE |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:90 /30Days |
NALOXONE 0.4 MG/ML CARPUJECT |
2 |
Generic |
$7.00 | N/A | None |
NALOXONE 0.4 MG/ML VIAL |
2 |
Generic |
$7.00 | N/A | None |
naloxone 1 mg/ml syringe |
2 |
Generic |
$7.00 | N/A | None |
NALTREXONE 50 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NAMENDA XR 14 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
NAMENDA XR 21 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
NAMENDA XR 28 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
NAMENDA XR 7 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
NAMENDA XR TITRATION PACK |
3 |
Preferred Brand |
$47.00 | N/A | P Q:56 /365Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAMZARIC 14 MG-10 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | P |
NAMZARIC 21 MG-10 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | P |
NAMZARIC 28 MG-10 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | P |
NAMZARIC 7 MG-10 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | P |
NAMZARIC TITRATION PACK |
3 |
Preferred Brand |
$47.00 | N/A | P |
Naproxen 125 mg/5 ml suspen |
2 |
Generic |
$7.00 | N/A | None |
NAPROXEN 250 MG ORAL TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
NAPROXEN 375 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
NAPROXEN 500 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
NAPROXEN DR 375 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
NAPROXEN DR 500 MG TABLET |
1* |
Preferred Generic |
$0.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NAPROXEN SODIUM 275 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
NAPROXEN SODIUM 550 MG TAB |
1* |
Preferred Generic |
$0.00 | N/A | None |
NARATRIPTAN HCL 1 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:9 /30Days |
NARATRIPTAN HCL 2.5 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:9 /30Days |
NARCAN 4 MG NASAL SPRAY |
3 |
Preferred Brand |
$47.00 | N/A | None |
NASONEX 50ug/1 120 SPRAY, METERED in 1 BOTTLE, PUMP |
3 |
Preferred Brand |
$47.00 | N/A | None |
NATACYN EYE DROPS |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NATEGLINIDE 120 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:90 /30Days |
NATEGLINIDE 60 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:180 /30Days |
NATPARA 100 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
NATPARA 25 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NATPARA 50 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
NATPARA 75 MCG DOSE CARTRIDGE |
5 |
Specialty Tier |
25% | N/A | P Q:2 /28Days |
NEBUPENT 300MG INHAL POWDER |
3 |
Preferred Brand |
$47.00 | N/A | P |
NECON 0.5-35-28 TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
NECON 7-7-7-28 TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
NEFAZODONE HCL 150MG TABLET (60 CT) |
3 |
Preferred Brand |
$47.00 | N/A | Q:120 /30Days |
NEFAZODONE HCL 250MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:72 /30Days |
NEFAZODONE HCL 50MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:360 /30Days |
NEFAZODONE HYDROCHLORIDE TABLETS 100MG 60 BOT |
3 |
Preferred Brand |
$47.00 | N/A | Q:180 /30Days |
NEFAZODONE HYDROCHLORIDE TABLETS 200MG 60 BOT |
3 |
Preferred Brand |
$47.00 | N/A | Q:90 /30Days |
NEO/POLYMYXIN/HC EAR TUBEX 10MG/3.5MG/100UNT |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEOMYC-POLYM-DEXAMET EYE OINTM [Poly-Dex] |
2 |
Generic |
$7.00 | N/A | None |
NEOMYC-POLYM-DEXAMETH EYE DROP |
2 |
Generic |
$7.00 | N/A | None |
NEOMYCIN SULFATE 500MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NEOMYCIN-BACITRACIN-POLY-HC 3.5-10K-1 OINTMENT |
3 |
Preferred Brand |
$47.00 | N/A | None |
NEOMYCIN-POLYMYXIN-HC 3.5-10K-10 SUSPENSION DROPS |
3 |
Preferred Brand |
$47.00 | N/A | None |
NEOMYCIN/POLY AMP 10X1 ML |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M |
3 |
Preferred Brand |
$47.00 | N/A | None |
NEOMYCIN/POLYMY/HYDRO OTIC SUS |
2 |
Generic |
$7.00 | N/A | None |
NEPHRAMINE SOLUTION FOR INJECTION |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
NERLYNX 40 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
NEULASTA 6MG/0.6ML SYRINGE |
5 |
Specialty Tier |
25% | N/A | P Q:1 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEUPOGEN 300 MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN 300MCG/ML VIAL |
5 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN 300ug/0.5mL 10 SYRINGE in 1 BOX / 0.5 mL in 1 SYRINGE |
5 |
Specialty Tier |
25% | N/A | P |
NEUPOGEN INJECTION 480MCG/0.8ML 10 X 0.8ML SYR |
5 |
Specialty Tier |
25% | N/A | P |
NEUPRO 1 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
NEUPRO 2 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
NEUPRO 3 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
NEUPRO 4 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
NEUPRO 6 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
NEUPRO 8 MG/24 HR PATCH |
3 |
Preferred Brand |
$47.00 | N/A | P Q:30 /30Days |
NEVANAC 0.1% DROPTAINER |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NEVIRAPINE 200 MG TABLET |
2 |
Generic |
$7.00 | N/A | Q:60 /30Days |
NEVIRAPINE ER 100 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NEVIRAPINE ER 400 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:30 /30Days |
NEXAVAR TABLETS 200MG 120 BOT |
5 |
Specialty Tier |
25% | N/A | P Q:120 /30Days |
NIACIN ER 1,000 MG TABLET [Niaspan ER] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NIACIN ER 500 MG TABLET [Niaspan ER] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NIACIN ER 750 MG TABLET [Niaspan ER] |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NIACOR 500 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NICARDIPINE 25 MG/10 ML VIAL |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Nicardipine hydrochloride 20 MG Oral Capsule |
2 |
Generic |
$7.00 | N/A | None |
Nicardipine hydrochloride 30 MG Oral Capsule |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NICOTROL NS NASAL SPRAY BOTTLE 10MG 4 X 10MG/ML INHL |
3 |
Preferred Brand |
$47.00 | N/A | Q:120 /30Days |
NIFEDIPINE ER 30 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NIFEDIPINE ER 30 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NIFEDIPINE ER 60 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NIFEDIPINE ER 60 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NIFEDIPINE ER 90 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NIFEDIPINE ER 90 MG TABLET |
2 |
Generic |
$7.00 | N/A | None |
NIKKI 3 MG-0.02 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NILANDRON 150 MG TABLET |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
NILUTAMIDE 150 MG TABLET [Nilandron] |
5 |
Specialty Tier |
25% | N/A | Q:30 /30Days |
NIMODIPINE 30 MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NINLARO 2.3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:3 /28Days |
NINLARO 3 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:3 /28Days |
NINLARO 4 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:3 /28Days |
NIPENT FOR INJECTION 10MG VIALS |
5 |
Specialty Tier |
25% | N/A | P |
NITRO-BID 2% OINTMENT |
3 |
Preferred Brand |
$47.00 | N/A | None |
Nitrofurantoin 25mg/5mL |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
NITROFURANTOIN MACROCRYSTALLINE 50 mg cap |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
Nitrofurantoin mcr 100 mg cap |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
NITROFURANTOIN MONO-MCR 100 MG |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
NITROGLYCERIN 0.2 MG/HR PATCH |
2 |
Generic |
$7.00 | N/A | None |
NITROGLYCERIN 0.3 MG TABLET SL |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NITROGLYCERIN 0.4 MG TABLET SL |
3 |
Preferred Brand |
$47.00 | N/A | None |
NITROGLYCERIN 0.4 MG/HR PATCH |
2 |
Generic |
$7.00 | N/A | None |
NITROGLYCERIN 0.6 MG TABLET SL |
3 |
Preferred Brand |
$47.00 | N/A | None |
NITROGLYCERIN 0.6 MG/HR PATCH |
2 |
Generic |
$7.00 | N/A | None |
Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
NITROGLYCERIN LINGUAL 0.4 MG |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NITROGLYCERIN TRANSOERMAL SYSTEM .1MG/HR 30 SYSTEM BOX |
2 |
Generic |
$7.00 | N/A | None |
NITROSTAT 0.3MG TABLET SL |
3 |
Preferred Brand |
$47.00 | N/A | None |
NITROSTAT 0.4 MG TABLET SL [Nitrotab] |
3 |
Preferred Brand |
$47.00 | N/A | None |
NITROSTAT 0.6MG TABLET SL |
3 |
Preferred Brand |
$47.00 | N/A | None |
NIZATIDINE 150 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NIZATIDINE 300 MG CAPSULE |
3 |
Preferred Brand |
$47.00 | N/A | None |
NORA-BE 0.35MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
Norditropin 10mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | P |
Norditropin 15mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | P |
Norditropin 5mg/1.5mL 1 SYRINGE, PLASTIC per CARTON / 1.5 mL in 1 SYRINGE, PLASTIC |
5 |
Specialty Tier |
25% | N/A | P |
NORDITROPIN FLEXPRO 30 MG/3 ML |
5 |
Specialty Tier |
25% | N/A | P |
NORETHINDRONE 0.35 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
NORETHINDRONE 5MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | None |
NORG-EE 0.18-0.215-0.25/0.035 |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NORG-ETHIN ESTRA 0.25-0.035 MG |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NORMOSOL -R INJ /D5W |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORMOSOL-M AND DEXTROSE 5% |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NORMOSOL-R PH 7.4 IV SOLUTION |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NORPACE 100MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
NORPACE 150MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | N/A | P |
NORTHERA 100 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:540 /30Days |
NORTHERA 200 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:270 /30Days |
NORTHERA 300 MG CAPSULE |
5 |
Specialty Tier |
25% | N/A | P Q:180 /30Days |
Nortrel (21 Day Regimen) 0.035; 1mg/1; mg/1 3 BLISTER PACK per CARTON / 21 TABLET per BLISTER PACK |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Nortrel (28 Day Regimen) 3 BLISTER PACK per CARTON / 1 KIT per BLISTER PACK |
3 |
Preferred Brand |
$47.00 | N/A | None |
NORTREL 1-0.035MG TABLET 28DAY |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
Nortrel 7/7/7 (28 Day Regimen) 6 POUCH per CARTON / 1 BLISTER PACK in 1 POUCH / 1 KIT in 1 BLISTER |
3 |
Preferred Brand |
$47.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORTRIPTYLINE 10 MG/5 ML SOL |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NORTRIPTYLINE HCL 25MG CAP |
1* |
Preferred Generic |
$0.00 | N/A | None |
NORTRIPTYLINE HCL 50 MG CAP |
2 |
Generic |
$7.00 | N/A | None |
NORTRIPTYLINE HCL 75 MG CAP |
2 |
Generic |
$7.00 | N/A | None |
Nortriptyline Hydrochloride 10mg/1 100 CAPSULE BOTTLE |
1* |
Preferred Generic |
$0.00 | N/A | None |
NORVASC 10MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NORVASC 2.5MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NORVASC 5 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NORVIR 100 MG POWDER PACKET |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:360 /30Days |
NORVIR 100 MG TABLET |
3 |
Preferred Brand |
$47.00 | N/A | Q:360 /30Days |
NORVIR 100mg/1 30 CAPSULE BOTTLE |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:360 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
NORVIR 80MG/ML ORAL SOLUTION |
4 |
Non-Preferred Drug |
$95.00 | N/A | Q:480 /30Days |
NOXAFIL 200MG/5ML SUSPENSION ORAL |
5 |
Specialty Tier |
25% | N/A | P |
NOXAFIL DR 100 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P |
NUEDEXTA 20; 10mg/1; mg/1 |
3 |
Preferred Brand |
$47.00 | N/A | Q:60 /30Days |
NULOJIX 250mg/1 1 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in |
5 |
Specialty Tier |
25% | N/A | P |
NUPLAZID 17 MG TABLET |
5 |
Specialty Tier |
25% | N/A | P Q:60 /30Days |
NUVARING 0.12-0.015 RING VAGINAL |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NYAMYC 100,000 UNITS/GM POWDER |
3 |
Preferred Brand |
$47.00 | N/A | None |
NYSTATIN 100,000 UNIT/GM CREAM |
2 |
Generic |
$7.00 | N/A | None |
NYSTATIN 100,000 UNIT/GM POWD |
3 |
Preferred Brand |
$47.00 | N/A | None |
NYSTATIN 100,000 UNITS/GM OINT |
2 |
Generic |
$7.00 | N/A | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Nystatin 100000[USP'U]/mL |
2 |
Generic |
$7.00 | N/A | None |
NYSTATIN 500,000 UNIT ORAL TAB |
2 |
Generic |
$7.00 | N/A | None |
NYSTATIN/TRIAMCINOLONE CRM |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NYSTATIN/TRIAMCINOLONE OINT 10000UNT/1MG |
4 |
Non-Preferred Drug |
$95.00 | N/A | None |
NYSTOP 100,000 UNITS/GM POWDER |
3 |
Preferred Brand |
$47.00 | N/A | None |