All *ANTIMYCOBACTERIAL AGENTS*

Capastat Sulfate SOLUTION RECONSTITUTED 1 GM INJECTION
Capastat Sulfate SOLUTION RECONSTITUTED 1 GM INJECTION

Capreomycin Sulfate

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
cycloSERINE Capsule 250 MG Oral
cycloSERINE Capsule 250 MG Oral

Tier: 3
PA Type: No Prior Authorization
ST: N
cycloSERINE Capsule 250 MG Oral
cycloSERINE Capsule 250 MG Oral

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Ethambutol HCl Tablet 100 MG Oral
Ethambutol HCl Tablet 100 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Ethambutol HCl Tablet 100 MG Oral
Ethambutol HCl Tablet 100 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Ethambutol HCl Tablet 100 MG Oral
Ethambutol HCl Tablet 100 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Ethambutol HCl Tablet 100 MG Oral
Ethambutol HCl Tablet 100 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Ethambutol HCl Tablet 100 MG Oral
Ethambutol HCl Tablet 100 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Ethambutol HCl Tablet 400 MG Oral
Ethambutol HCl Tablet 400 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Ethambutol HCl Tablet 400 MG Oral
Ethambutol HCl Tablet 400 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Ethambutol HCl Tablet 400 MG Oral
Ethambutol HCl Tablet 400 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Ethambutol HCl Tablet 400 MG Oral
Ethambutol HCl Tablet 400 MG Oral

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