All *HEMATOLOGICAL AGENTS - MISC.*

Activase SOLUTION RECONSTITUTED 100 MG Intravenous
Activase SOLUTION RECONSTITUTED 100 MG Intravenous

Alteplase

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Activase SOLUTION RECONSTITUTED 50 MG Intravenous
Activase SOLUTION RECONSTITUTED 50 MG Intravenous

Alteplase

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Advate Solution Reconstituted 1000 UNIT Intravenous
Advate Solution Reconstituted 1000 UNIT Intravenous

Antihemophil Factor (rAHF-PFM)

Tier: 4
PA Type: PA Applies
PA Group: Factor concentrate Products
Advate Solution Reconstituted 1000 UNIT Intravenous
Advate Solution Reconstituted 1000 UNIT Intravenous

Antihemophil Factor (rAHF-PFM)

Tier: 4
PA Type: PA Applies
PA Group: Factor concentrate Products
Advate Solution Reconstituted 1000 UNIT Intravenous
Advate Solution Reconstituted 1000 UNIT Intravenous

Antihemophil Factor (rAHF-PFM)

Tier: 4
PA Type: PA Applies
PA Group: Factor concentrate Products
Advate Solution Reconstituted 1500 UNIT Intravenous
Advate Solution Reconstituted 1500 UNIT Intravenous

Antihemophil Factor (rAHF-PFM)

Tier: 4
PA Type: PA Applies
PA Group: Factor concentrate Products
Advate Solution Reconstituted 1500 UNIT Intravenous
Advate Solution Reconstituted 1500 UNIT Intravenous

Antihemophil Factor (rAHF-PFM)

Tier: 4
PA Type: PA Applies
PA Group: Factor concentrate Products
Advate Solution Reconstituted 1500 UNIT Intravenous
Advate Solution Reconstituted 1500 UNIT Intravenous

Antihemophil Factor (rAHF-PFM)

Tier: 4
PA Type: PA Applies
PA Group: Factor concentrate Products
Advate Solution Reconstituted 2000 UNIT Intravenous
Advate Solution Reconstituted 2000 UNIT Intravenous

Antihemophil Factor (rAHF-PFM)

Tier: 4
PA Type: PA Applies
PA Group: Factor concentrate Products
Advate Solution Reconstituted 2000 UNIT Intravenous
Advate Solution Reconstituted 2000 UNIT Intravenous

Antihemophil Factor (rAHF-PFM)

Tier: 4
PA Type: PA Applies
PA Group: Factor concentrate Products
Advate Solution Reconstituted 250 UNIT Intravenous
Advate Solution Reconstituted 250 UNIT Intravenous

Antihemophil Factor (rAHF-PFM)

Tier: 4
PA Type: PA Applies
PA Group: Factor concentrate Products
Advate Solution Reconstituted 250 UNIT Intravenous
Advate Solution Reconstituted 250 UNIT Intravenous

Antihemophil Factor (rAHF-PFM)

Tier: 4
PA Type: PA Applies
PA Group: Factor concentrate Products