Standard Health Pals Formulary
Amikacin 250 mg / 1 ml Vial for Infusion — 2 ml Vial (Generic for Amikin)
Coverage Level – 100%
Copay – $0
Limitations – No more than 30 days’ supply; Maximum 14 vials in 30 days
Restrictions – Health Pals Mail Order Pharmacy Network
Comments – Generic for Amikin