2023 Medicare Part D Plan Formulary Information |
Network Health Medicare Go (PPO) (H5215-009-0)
Benefit Details
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. Call drug plan for more details. |
The Network Health Medicare Go (PPO) (H5215-009-0) Formulary Drugs Starting with the Letter H in Waukesha County, WI: CMS MA Region 14 which includes: WI
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Drugs Starting with Letter H
Drug Name |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
HAEGARDA 2,000 UNIT VIAL |
5 |
Specialty Tier |
30% | N/A | P |
HAEGARDA 3,000 UNIT VIAL |
5 |
Specialty Tier |
30% | N/A | P |
HAILEY 24 FE 1 MG-20 MCG TABLET [Tarina Fe 1/20] |
2* |
Generic |
$8.00 | $0.00 | None |
HALCINONIDE 0.1% CREAM (g) [Halog -E] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HALCION 0.25 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
HALDOL DECANOATE 100MG/ML INJECTION |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
HALDOL DECANOATE 50MG/ML INJECTION |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
HALOBETASOL PROP 0.05% CREAM |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
Halobetasol Propionate 0.5mg/g 1 TUBE per CARTON / 50 g in 1 TUBE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HALOG 0.1% SOLUTION |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Halog 1mg/g 60 g in 1 TUBE |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
HALOG OINTMENT 1mg/g 60 g in 1 TUBE [HALOG] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
HALOPERIDOL 0.5 MG TABLET [Haldol] |
2* |
Generic |
$8.00 | $0.00 | None |
HALOPERIDOL 1 MG TABLET [Haldol] |
2* |
Generic |
$8.00 | $0.00 | None |
HALOPERIDOL 10 MG TABLET |
2* |
Generic |
$8.00 | $0.00 | None |
HALOPERIDOL 2 MG TABLET [Haldol] |
2* |
Generic |
$8.00 | $0.00 | None |
HALOPERIDOL 20MG TABLET (100 CT) |
2* |
Generic |
$8.00 | $0.00 | None |
HALOPERIDOL 5 MG TABLET [Haldol] |
2* |
Generic |
$8.00 | $0.00 | None |
HALOPERIDOL DEC 100 MG/ML VIAL [Haldol Decanoate] |
2* |
Generic |
$8.00 | $0.00 | None |
HALOPERIDOL DEC 50 MG/ML VIAL [Haldol Decanoate] |
2* |
Generic |
$8.00 | $0.00 | None |
HALOPERIDOL DEC 50 MG/ML VIAL [Haldol Decanoate] |
2* |
Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HALOPERIDOL DEC 500 MG/5 ML VIAL [Haldol Decanoate] |
2* |
Generic |
$8.00 | $0.00 | None |
HALOPERIDOL LAC 2 MG/ML CONC |
2* |
Generic |
$8.00 | $0.00 | None |
HALOPERIDOL LAC 5 MG/ML VIAL |
2* |
Generic |
$8.00 | $0.00 | None |
HARVONI 33.75-150 MG PELLET PACKET |
5 |
Specialty Tier |
30% | N/A | P Q:28 /28Days |
HARVONI 45-200 MG PELLET PACKET |
5 |
Specialty Tier |
30% | N/A | P Q:56 /28Days |
HARVONI 90-400 MG TABLET |
5 |
Specialty Tier |
30% | N/A | P Q:28 /28Days |
HAVRIX 1,440 UNITS/ML SYRINGE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HAVRIX HEPATITIS A VACCINE INJECTION |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HEMADY 20 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
HEPARIN 10,000 UNIT/10 ML VIAL |
2* |
Generic |
$8.00 | $0.00 | None |
HEPARIN SOD 20,000 UNIT/ML VIAL |
2* |
Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HEPARIN SOD 5,000 UNIT/ML VIAL |
2* |
Generic |
$8.00 | $0.00 | None |
HEPARIN SODIUM INJECTION |
2* |
Generic |
$8.00 | $0.00 | None |
Hepatitis B Surface Antigen Vaccine 0.01 MG/ML Prefilled 0.5 ML Syringe [Recombivax] |
3 |
Preferred Brand |
$42.00 | $105.00 | P |
HEPLISAV-B 20 MCG/0.5 ML SYRINGE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HETLIOZ 20 MG CAPSULE |
5 |
Specialty Tier |
30% | N/A | P Q:30 /30Days |
HETLIOZ LQ 4 MG/ML ORAL SUSPENSION |
5 |
Specialty Tier |
30% | N/A | P Q:158 /30Days |
HIBERIX VACCINE WITH DILUENT |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HIPREX 1 GM TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
HORIZANT ER 300 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
HORIZANT ER 600 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | P |
HUMALOG 100 UNIT/ML VIAL |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMALOG 100 UNITS/ML CARTRIDGE |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMALOG 200 UNITS/ML KWIKPEN |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMALOG JR 100 UNIT/ML KWIKPEN |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMALOG KWIKPEN INJECTION |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMALOG MIX 50/50 VIAL |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMALOG MIX 75/25 VIAL |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMALOG MIX KWIKPEN INJECTION |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMALOG MIX KWIKPEN INJECTION SUSPENSION |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMALOG TEMPO PEN 100 UNIT/ML INSULN PEN |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMATROPE 12MG CARTRIDGE |
5 |
Specialty Tier |
30% | N/A | P |
HUMATROPE 24MG CARTRIDGE |
5 |
Specialty Tier |
30% | N/A | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMATROPE 6MG CARTRIDGE |
5 |
Specialty Tier |
30% | N/A | P |
HUMIRA 10 MG/0.1 ML SYRINGEKIT |
5 |
Specialty Tier |
30% | N/A | P Q:2 /28Days |
Humira 2 KIT per CARTON / 1 KIT in 1 KIT |
5 |
Specialty Tier |
30% | N/A | P Q:4 /28Days |
HUMIRA 20 MG/0.2 ML SYRINGEKIT |
5 |
Specialty Tier |
30% | N/A | P Q:2 /28Days |
HUMIRA 40 MG/0.4 ML PEN IJ KIT |
5 |
Specialty Tier |
30% | N/A | P Q:4 /28Days |
HUMIRA 40 MG/0.4 ML SYRINGEKIT |
5 |
Specialty Tier |
30% | N/A | P Q:4 /28Days |
HUMIRA 40 MG/0.8 ML PEN |
5 |
Specialty Tier |
30% | N/A | P Q:4 /28Days |
HUMIRA PED CROHNS 80 MG/0.8 ML SYRINGEKIT |
5 |
Specialty Tier |
30% | N/A | P Q:3 /30Days |
HUMIRA PEDIATR CROHN'S 80-40MG SYRINGEKIT |
5 |
Specialty Tier |
30% | N/A | P Q:2 /30Days |
HUMIRA PEN KIT 40MG-70% 1 PKGCOM |
5 |
Specialty Tier |
30% | N/A | P Q:6 /28Days |
HUMIRA PEN PSORIASIS-UVEITIS |
5 |
Specialty Tier |
30% | N/A | P Q:4 /28Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HUMIRA(CF) PEN 80 MG/0.8 ML PEN IJ KIT |
5 |
Specialty Tier |
30% | N/A | P Q:2 /28Days |
HUMIRA(CF) PEN CRHN-UC-HS 80MG PEN IJ KIT |
5 |
Specialty Tier |
30% | N/A | P Q:3 /28Days |
HUMIRA(CF) PEN PEDI UC 80 MG PEN IJ KIT |
5 |
Specialty Tier |
30% | N/A | P Q:4 /180Days |
HUMIRA(CF) PEN PS-UV-AHS 80-40 PEN IJ KIT |
5 |
Specialty Tier |
30% | N/A | P Q:3 /28Days |
HUMULIN 70/30 KWIKPEN |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMULIN 70/30 VIAL |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMULIN N 100 UNITS/ML KWIKPEN |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMULIN N 100U/ML VIAL |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMULIN R 100U/ML VIAL |
4 |
Non-Preferred Drug |
$35 max* | $237.00 | P |
HUMULIN R 500 UNITS/ML KWIKPEN |
3 |
Preferred Brand |
$35 max* | $105.00 | P |
HUMULIN R 500U/ML VIAL |
3 |
Preferred Brand |
$35 max* | $105.00 | P |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDRALAZINE 10 MG TABLET [Apresoline] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDRALAZINE 100 MG TABLET [Apresoline] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDRALAZINE 25 MG TABLET |
2* |
Generic |
$8.00 | $0.00 | None |
HYDRALAZINE 50 MG TABLET |
2* |
Generic |
$8.00 | $0.00 | None |
HYDREA 500MG CAPSULE |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE [Microzide] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 12.5 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 25 MG TABLET |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
HYDROCHLOROTHIAZIDE 50 MG TABLET [Zide] |
1* |
Preferred Generic |
$2.00 | $0.00 | None |
HYDROCODONE ER 10 MG CAPSULE 12H [Zohydro] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:90 /30Days |
HYDROCODONE ER 100 MG TABLET 24H [Hysingla ER] |
5 |
Specialty Tier |
30% | N/A | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCODONE ER 120 MG TABLET 24H [Hysingla ER] |
5 |
Specialty Tier |
30% | N/A | Q:60 /30Days |
HYDROCODONE ER 15 MG CAPSULE 12H [Zohydro] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:90 /30Days |
HYDROCODONE ER 20 MG CAPSULE 12H [Zohydro] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:90 /30Days |
HYDROCODONE ER 20 MG TABLET 24H [Hysingla ER] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
HYDROCODONE ER 30 MG CAPSULE 12H [Zohydro] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:90 /30Days |
HYDROCODONE ER 30 MG TABLET 24H [Hysingla ER] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
HYDROCODONE ER 40 MG CAPSULE 12H [Zohydro] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:90 /30Days |
HYDROCODONE ER 40 MG TABLET 24H [Hysingla ER] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
HYDROCODONE ER 50 MG CAPSULE 12H [Zohydro] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:90 /30Days |
HYDROCODONE ER 60 MG TABLET 24H [Hysingla ER] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
HYDROCODONE ER 80 MG TABLET 24H [Hysingla ER] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCODONE-ACETAMIN 10-300 MG TABLET [Xodol] |
2* |
Generic |
$8.00 | $0.00 | Q:390 /30Days |
HYDROCODONE-ACETAMIN 10-325 MG TABLET [Norco] |
2* |
Generic |
$8.00 | $0.00 | Q:360 /30Days |
HYDROCODONE-ACETAMIN 5-300 MG TABLET [Xodol] |
2* |
Generic |
$8.00 | $0.00 | Q:390 /30Days |
HYDROCODONE-ACETAMIN 5-325 MG TABLET [Norco] |
2* |
Generic |
$8.00 | $0.00 | Q:360 /30Days |
HYDROCODONE-ACETAMIN 7.5-300 TABLET [Xodol] |
2* |
Generic |
$8.00 | $0.00 | Q:390 /30Days |
HYDROCODONE-ACETAMIN 7.5-325 TABLET [Norco] |
2* |
Generic |
$8.00 | $0.00 | Q:360 /30Days |
HYDROCODONE-ACETAMN 7.5-325/15 SOLUTION [Hycet] |
2* |
Generic |
$8.00 | $0.00 | Q:5550 /30Days |
HYDROCODONE-IBUPROFEN 10-200 TABLET [Xylon 10] |
2* |
Generic |
$8.00 | $0.00 | Q:50 /30Days |
HYDROCODONE-IBUPROFEN 5-200 MG |
2* |
Generic |
$8.00 | $0.00 | Q:50 /30Days |
HYDROCODONE-IBUPROFEN 7.5-200 TABLET [Vicoprofen] |
2* |
Generic |
$8.00 | $0.00 | Q:50 /30Days |
HYDROCORT-PRAMOXINE 1%-1% CREAM w/APPL [Zone A] |
2* |
Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCORTISON-ACETIC ACID SOLUTION DROPS [VoSoL HC] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE 1% CREAM |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE 1% OINTMENT |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE 10 MG TABLET [Hydrocortone] |
2* |
Generic |
$8.00 | $0.00 | None |
Hydrocortisone 10 MG/ML Topical Cream [Ala-Cort] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE 100 MG/60 ML |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE 2.5% CREAM /PE APP [Proctozone-HC] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE 2.5% LOTION |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE 2.5% OINTMENT |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE 20 MG TABLET [Cortef] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE 5 MG TABLET [Cortef] |
2* |
Generic |
$8.00 | $0.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROCORTISONE BUTY 0.1% CREAM (G) [Locoid] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
HYDROCORTISONE BUTYR 0.1% LOTION [Locoid] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HYDROCORTISONE BUTYR 0.1% OINTMENT [Locoid] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE BUTYR 0.1% SOLUTION [Locoid] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE VAL 0.2% CREAM (G) [Westcort] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROCORTISONE VAL 0.2% OINTMENT [Westcort] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROMORPHONE 1 MG/ML SOLUTION LIQUID [Dilaudid] |
2* |
Generic |
$8.00 | $0.00 | Q:2400 /30Days |
HYDROMORPHONE 10 MG/ML VIAL [Dilaudid-HP] |
2* |
Generic |
$8.00 | $0.00 | Q:240 /30Days |
HYDROMORPHONE 2 MG TABLET [Dilaudid] |
2* |
Generic |
$8.00 | $0.00 | Q:180 /30Days |
HYDROMORPHONE 4 MG TABLET [Dilaudid] |
2* |
Generic |
$8.00 | $0.00 | Q:180 /30Days |
HYDROMORPHONE 50 MG/5 ML VIAL [Dilaudid-HP] |
2* |
Generic |
$8.00 | $0.00 | Q:240 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROMORPHONE 8 MG TABLET [Dilaudid] |
2* |
Generic |
$8.00 | $0.00 | Q:180 /30Days |
HYDROMORPHONE HCL ER 12 MG TABLET 24H [Exalgo] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
HYDROMORPHONE HCL ER 16 MG TABLET 24H [Exalgo] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
HYDROMORPHONE HCL ER 32 MG TABLET 24H [Exalgo] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
HYDROMORPHONE HCL ER 8 MG TABLET 24H [Exalgo] |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
HYDROXYCHLOROQUINE 100 MG TABLET |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HYDROXYCHLOROQUINE 200 MG TABLET [Quineprox] |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROXYCHLOROQUINE 300 MG TABLET |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HYDROXYCHLOROQUINE 400 MG TABLET |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HYDROXYUREA 500 MG CAPSULE |
2* |
Generic |
$8.00 | $0.00 | None |
HYDROXYZINE 10 MG/5 ML SYRUP SOLUTION [Atarax] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYDROXYZINE HCL 10 MG TABLET [Rezine] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HYDROXYZINE HCL 25 MG TABLET [Atarax] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HYDROXYZINE HCL 50 MG TABLET [Atarax] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HYDROXYZINE PAM 100MG CAPSULE |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HYDROXYZINE PAM 25 MG CAPSULE [Vistaril] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HYDROXYZINE PAM 50 MG CAPSULE [Vistaril] |
3 |
Preferred Brand |
$42.00 | $105.00 | None |
HYFTOR 0.2% GEL |
5 |
Specialty Tier |
30% | N/A | P |
HYSINGLA ER 100 MG TABLET |
5 |
Specialty Tier |
30% | N/A | Q:60 /30Days |
HYSINGLA ER 120 MG TABLET |
5 |
Specialty Tier |
30% | N/A | Q:60 /30Days |
HYSINGLA ER 20 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:150 /30Days |
HYSINGLA ER 30 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
Drug Name |
Tier Nbr. |
Tier Description |
30-Day Preferred Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
HYSINGLA ER 40 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
HYSINGLA ER 60 MG TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | Q:60 /30Days |
HYSINGLA ER 80 MG TABLET |
5 |
Specialty Tier |
30% | N/A | Q:60 /30Days |
HYZAAR 100-12.5 TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
HYZAAR 100-25 TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |
HYZAAR 50-12.5 TABLET |
4 |
Non-Preferred Drug |
$95.00 | $237.00 | None |