All *ANTIDIARRHEAL/PROBIOTIC AGENTS*

Diphenoxylate-Atropine Liquid 2.5-0.025 MG/5ML Oral
Diphenoxylate-Atropine Liquid 2.5-0.025 MG/5ML Oral

Tier: 3
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral
Diphenoxylate-Atropine Tablet 2.5-0.025 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N