All *ANTIDOTES AND SPECIFIC ANTAGONISTS*

Acetadote Solution 200 MG/ML Intravenous
Acetadote Solution 200 MG/ML Intravenous

Acetylcysteine

Tier: 3
PA Type: No Prior Authorization
ST: N
Acetylcysteine Solution 200 MG/ML Intravenous
Acetylcysteine Solution 200 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Acetylcysteine Solution 200 MG/ML Intravenous
Acetylcysteine Solution 200 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Acetylcysteine Solution 200 MG/ML Intravenous
Acetylcysteine Solution 200 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Acetylcysteine Solution 200 MG/ML Intravenous
Acetylcysteine Solution 200 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Acetylcysteine Solution 200 MG/ML Intravenous
Acetylcysteine Solution 200 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Acetylcysteine Solution 200 MG/ML Intravenous
Acetylcysteine Solution 200 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Acetylcysteine Solution 200 MG/ML Intravenous
Acetylcysteine Solution 200 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Acetylcysteine Solution 200 MG/ML Intravenous
Acetylcysteine Solution 200 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Acetylcysteine Solution 200 MG/ML Intravenous
Acetylcysteine Solution 200 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Acetylcysteine Solution 200 MG/ML Intravenous
Acetylcysteine Solution 200 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Andexxa Solution Reconstituted 100 MG Intravenous
Andexxa Solution Reconstituted 100 MG Intravenous

Coag Fact Xa Inactivated-zhzo

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N