
1st Medx-Patch/ Lidocaine Patch 4-0.0375-5-20 % External
Lido-Capsaicin-Men-Methyl Sal
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N

A.A.G.C. Kit in TeroDerm CREAM 8-4-10-4 % EXTERNAL
Amantad-Amitrip-Gabap-Cycloben
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
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