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This list is not intended to imply coverage, so please ... · your prescription drug benefit. ......

Date post:	03-Apr-2018
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This list is not intended to imply coverage, so please refer to your plan document (s) for detailed information about your drug benefit coverage, Prior Authorization requirements, or restrictions.

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Page 1: This list is not intended to imply coverage, so please ... · your prescription drug benefit. ... azithromycin baclofen benazepril ... metronidazole topical metronidazole vaginal

This list is not intended to imply coverage, so please refer to your plan document (s) for detailed information about your drug benefit coverage, Prior Authorization requirements, or restrictions.

Page 2: This list is not intended to imply coverage, so please ... · your prescription drug benefit. ... azithromycin baclofen benazepril ... metronidazole topical metronidazole vaginal

This list is not intended to imply coverage, so please refer to your plan document (s) for detailed information about your drug benefit coverage, Prior Authorization requirements, or restrictions.

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