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Generated Narrative: Basic FormularyItem-D3004t-1049640
Last updated: 2021-08-22 18:36:03+0000
Profile: Formulary Item
Formulary Reference: InsurancePlan Sample Medicare Advantage Part D Formulary D3004t
Availability Status: active
Pharmacy Benefit Type: 3 month out of network retail
Drug Tier ID: Preferred Brand
Availability Period: 2021-01-01 --> 2021-12-31
Prior Authorization: true
Prior Authorization New Starts Only: true
Step Therapy Limit: true
Step Therapy Limit New Starts Only: false
Quantity Limit: true
code: Formulary Item
subject: MedicationKnowledge acetaminophen 325 MG / oxycodone hydrochloride 5 MG Oral Tablet [Percocet]