All *DERMATOLOGICALS*

1st Medx-Patch/ Lidocaine Patch 4-0.0375-5-20 % External
1st Medx-Patch/ Lidocaine Patch 4-0.0375-5-20 % External

Lido-Capsaicin-Men-Methyl Sal

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
7T Lido Gel 2 % External
7T Lido Gel 2 % External

Lidocaine HCl

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
A.A.G.C. Kit in TeroDerm CREAM 8-4-10-4 % EXTERNAL
A.A.G.C. Kit in TeroDerm CREAM 8-4-10-4 % EXTERNAL

Amantad-Amitrip-Gabap-Cycloben

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
A.A.G.C. Kit in TeroDerm CREAM 8-4-10-4 % EXTERNAL
A.A.G.C. Kit in TeroDerm CREAM 8-4-10-4 % EXTERNAL

Amantad-Amitrip-Gabap-Cycloben

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Absorica CAPSULE 10 MG ORAL
Absorica CAPSULE 10 MG ORAL

ISOtretinoin

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Absorica CAPSULE 10 MG ORAL
Absorica CAPSULE 10 MG ORAL

ISOtretinoin

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Absorica CAPSULE 20 MG ORAL
Absorica CAPSULE 20 MG ORAL

ISOtretinoin

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Absorica CAPSULE 20 MG ORAL
Absorica CAPSULE 20 MG ORAL

ISOtretinoin

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Absorica CAPSULE 25 MG ORAL
Absorica CAPSULE 25 MG ORAL

ISOtretinoin

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Absorica CAPSULE 25 MG ORAL
Absorica CAPSULE 25 MG ORAL

ISOtretinoin

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Absorica CAPSULE 30 MG ORAL
Absorica CAPSULE 30 MG ORAL

ISOtretinoin

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Absorica CAPSULE 30 MG ORAL
Absorica CAPSULE 30 MG ORAL

ISOtretinoin

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