
Active Injection BLM-1 KIT 6 & 0.25 & 1 MG/ML-%-% INJECTION
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N

Active Injection BM KIT 6 & 0.25 MG/ML-% INJECTION
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N

Active Injection DL KIT 10 & 1 MG/ML-% INJECTION
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N

Active Injection DLM KIT 10 & 0.25 & 1 MG/ML-%-% INJECTION
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N

Active Injection Kit L KIT 40 & 1 MG/ML-% Injection
Methylprednisolone Ace-Lido
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N

Active Injection KL-3 KIT 40-1 MG/ML-% COMBINATION
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N

Active Injection KM Kit 40-0.5 MG/ML-% Injection
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N

Active Injection LM-DEP-1 Kit 80 & 0.25 & 1 MG/ML-%-% Injection
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N

Active Injection LM-DEP-2 Kit 40 & 0.25 & 1 MG/ML-%-% Injection
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
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