Aptiom TABLET 200 MG ORAL
Tier: 3
PA Type: No Prior Authorization
ST: N
Aptiom TABLET 400 MG ORAL
Tier: 3
PA Type: No Prior Authorization
ST: N
Aptiom TABLET 600 MG ORAL
Tier: 3
PA Type: No Prior Authorization
ST: N
Aptiom TABLET 800 MG ORAL
Tier: 3
PA Type: No Prior Authorization
ST: N
Banzel Suspension 40 MG/ML Oral
Tier: 3
PA Type: No Prior Authorization
ST: N
Banzel TABLET 200 MG ORAL
Tier: 3
PA Type: No Prior Authorization
ST: N
Banzel TABLET 400 MG ORAL
Tier: 3
PA Type: No Prior Authorization
ST: N
Briviact SOLUTION 10 MG/ML ORAL
Tier: 3
PA Type: No Prior Authorization
ST: N
Briviact SOLUTION 50 MG/5ML Intravenous
Tier: 3
PA Type: No Prior Authorization
ST: N
Briviact SOLUTION 50 MG/5ML Intravenous
Tier: 3
PA Type: No Prior Authorization
ST: N
Briviact TABLET 10 MG ORAL
Tier: 3
PA Type: No Prior Authorization
ST: N
Briviact TABLET 100 MG ORAL
Tier: 3
PA Type: No Prior Authorization
ST: N