Synjardy XR Tablet Extended Release NF 2 Formulary Enhancement N/A 24 Hour 10-1000 MG Oral Synjardy XR Tablet Extended Release NF 2 Formulary Enhancement N/A 24 Hour 12.5-1000 MG Oral Synjardy XR Tablet Extended Release NF 2 Formulary Enhancement N/A 24 Hour 25-1000 MG Oral Synjardy XR Tablet Extended Release NF 2 Formulary Enhancement N/A 24 Hour 5-1000 MG Oral Triamterene-HCTZ CAPSULE 50-25 1 NF CMS Required Deletion N/A MG Oral Tri-Mili Tablet 0.18/0.215/0.25 MG-35 NF 1 Formulary Enhancement N/A MCG Oral
Synjardy XR Tablet Extended Release 24 Hour 10-1000 MG Oral NF 2 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 12.5-1000 MG Oral NF 2 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 25-1000 MG Oral NF 2 Formulary Enhancement N/A Synjardy XR Tablet Extended Release 24 Hour 5-1000 MG Oral NF 2 Formulary Enhancement N/A Triamterene-HCTZ CAPSULE 50-25 MG Oral 1 NF CMS Required Deletion N/A Tri-Mili Tablet 0.18/0.215/0.25 MG-35 MCG Oral NF 1 Formulary Enhancement N/A
AgeWell-MMP_2018_Addendum_Eff_08012018.docx