Transcription of NLPDP Coverage Status Table December 2021
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NLPDP Coverage Status Table December 2021
NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP02234510282 TABLETOPENI nitial and maintenance fills are limited to a maximum 30 TABLETOPENI nitial and maintenance fills are limited to a maximum 30 10 MG/ML SOLUTIONOPENI nitial and maintenance fills are limited to a maximum 30 150MG TABLETOPENI nitial and maintenance fills are limited to a maximum 30 300MG TABLETOPENI nitial and maintenance fills are limited to a maximum 30 IHLES PASTE FORMULA ALBALON A/SULAMYD 10% 1 5MG/50MG 100-25 MG 50-25 MG 100 MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 200MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 25 MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 50MG TABLETSPEC AUTHI nitial fills are limited to a maximum 30 30 MG 60 MG MICRO 67 MG 200 MG CR 100MG/25MG CR 200MG/50MG LA 100 MG TABLET LA 200 MG TABLET LA 300 MG December 2021 NLPDP Coverage Status Table December 2021 DINL abel Nam eB enefit StatusLim itationNIDPFPACK AGE SIZENLPDP LIST PRICENIDPF MLP02414570 ABBOTT CI
DIN Label Name Benefit Status Limitation NIDPF PACKAGE SIZE NLPDP LIST PRICE NIDPF MLP 02234510 282 TABLET OPEN Initial and maintenance fills are limited to a ... OPEN None Yes 90 0.2553 0.2553 02426757 ACH-CAPECITABINE 150MG TABLET SPEC AUTH None Yes 60 0.4987 0.4987 02426765 ACH-CAPECITABINE 500MG TABLET SPEC AUTH None Yes …
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