Ampicillin 2 gram Vial for Infusion (Generic for Omnipen and Principen)

Coverage Level – 100%

Copay – $0

Limitations – No more than 30 days’ supply

Restrictions – Health Pals Mail Order Pharmacy Network

Comments – Must be shipped to either a Physician’s office or an Infusion Clinic; Generic for Omnipen and Principen