All *HEMATOPOIETIC AGENTS*

Abaneu-SL Tablet Sublingual 600-600 MCG Sublingual
Abaneu-SL Tablet Sublingual 600-600 MCG Sublingual

Cyanocobalamin-Methylcobalamin

Tier: 1
PA Type: No Prior Authorization
ST: N
Active FE Tablet 75-1.25 MG Oral
Active FE Tablet 75-1.25 MG Oral

Tier: 3
PA Type: No Prior Authorization
ST: N
Active FE Tablet 75-1.25 MG Oral
Active FE Tablet 75-1.25 MG Oral

Tier: 3
PA Type: No Prior Authorization
ST: N
Adakveo Solution 100 MG/10ML Intravenous
Adakveo Solution 100 MG/10ML Intravenous

Crizanlizumab-tmca

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Airavite Tablet 2.5-25-1 MG Oral
Airavite Tablet 2.5-25-1 MG Oral

Folic Acid-Vit B6-Vit B12

Tier: 1
PA Type: No Prior Authorization
ST: N
Animi-3 Capsule 1 MG Oral
Animi-3 Capsule 1 MG Oral

FA-B6-B12-D-Omega 3-Phytoster

Tier: 3
PA Type: No Prior Authorization
ST: N
Animi-3/Vitamin D Capsule 1 MG Oral
Animi-3/Vitamin D Capsule 1 MG Oral

FA-B6-B12-D-Omega 3-Phytoster

Tier: 3
PA Type: No Prior Authorization
ST: N
Aranesp (Albumin Free) SOLUTION 100 MCG/ML INJECTION
Aranesp (Albumin Free) SOLUTION 100 MCG/ML INJECTION

Darbepoetin Alfa

Tier: Non-Formulary
PA Type: PA Applies
PA Group: Aranesp
Aranesp (Albumin Free) SOLUTION 100 MCG/ML INJECTION
Aranesp (Albumin Free) SOLUTION 100 MCG/ML INJECTION

Darbepoetin Alfa

Tier: Non-Formulary
PA Type: PA Applies
PA Group: Aranesp
Aranesp (Albumin Free) SOLUTION 200 MCG/ML INJECTION
Aranesp (Albumin Free) SOLUTION 200 MCG/ML INJECTION

Darbepoetin Alfa

Tier: Non-Formulary
PA Type: PA Applies
PA Group: Aranesp
Aranesp (Albumin Free) SOLUTION 25 MCG/ML INJECTION
Aranesp (Albumin Free) SOLUTION 25 MCG/ML INJECTION

Darbepoetin Alfa

Tier: Non-Formulary
PA Type: PA Applies
PA Group: Aranesp
Aranesp (Albumin Free) SOLUTION 25 MCG/ML INJECTION
Aranesp (Albumin Free) SOLUTION 25 MCG/ML INJECTION

Darbepoetin Alfa

Tier: Non-Formulary
PA Type: PA Applies
PA Group: Aranesp