All *HEMOSTATICS*

Actifoam Collagen Sponge EXTERNAL
Actifoam Collagen Sponge EXTERNAL

Absorbable Collagen Hemostat

Tier: 3
PA Type: No Prior Authorization
ST: N
Actifoam Collagen Sponge EXTERNAL
Actifoam Collagen Sponge EXTERNAL

Absorbable Collagen Hemostat

Tier: 3
PA Type: No Prior Authorization
ST: N
Amicar Solution 0.25 GM/ML Oral
Amicar Solution 0.25 GM/ML Oral

Aminocaproic Acid

Tier: 3
PA Type: No Prior Authorization
ST: N
Amicar Tablet 1000 MG Oral
Amicar Tablet 1000 MG Oral

Aminocaproic Acid

Tier: 3
PA Type: No Prior Authorization
ST: N
Amicar Tablet 500 MG Oral
Amicar Tablet 500 MG Oral

Aminocaproic Acid

Tier: 3
PA Type: No Prior Authorization
ST: N
Aminocaproic Acid Solution 0.25 GM/ML Oral
Aminocaproic Acid Solution 0.25 GM/ML Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Aminocaproic Acid Solution 0.25 GM/ML Oral
Aminocaproic Acid Solution 0.25 GM/ML Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Aminocaproic Acid Solution 0.25 GM/ML Oral
Aminocaproic Acid Solution 0.25 GM/ML Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Aminocaproic Acid Solution 0.25 GM/ML Oral
Aminocaproic Acid Solution 0.25 GM/ML Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Aminocaproic Acid Solution 250 MG/ML Intravenous
Aminocaproic Acid Solution 250 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Aminocaproic Acid Solution 250 MG/ML Intravenous
Aminocaproic Acid Solution 250 MG/ML Intravenous

Tier: 1
PA Type: No Prior Authorization
ST: N
Aminocaproic Acid Solution 250 MG/ML Intravenous
Aminocaproic Acid Solution 250 MG/ML Intravenous

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