Standard Health Pals Formulary
Diphenoxylate 2.5 mg and Atropine 0.025 mg Combination Tablet
Coverage Level – 100%
Copay – $0
Limitations – No more than 30 days’ supply
Restrictions – Health Pals Mail Order Pharmacy Network
Comments – N/A
Coverage Level – 100%
Copay – $0
Limitations – No more than 30 days’ supply
Restrictions – Health Pals Mail Order Pharmacy Network
Comments – N/A
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