All *MEDICAL DEVICES AND SUPPLIES*

1st Tier Unifine Pentips 29G X 12MM
1st Tier Unifine Pentips 29G X 12MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips 31G X 5 MM
1st Tier Unifine Pentips 31G X 5 MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips 31G X 6 MM
1st Tier Unifine Pentips 31G X 6 MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips 31G X 8 MM
1st Tier Unifine Pentips 31G X 8 MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips 32G X 4 MM
1st Tier Unifine Pentips 32G X 4 MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips 32G X 6 MM
1st Tier Unifine Pentips 32G X 6 MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips 33G X 4 MM
1st Tier Unifine Pentips 33G X 4 MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips Plus 29G X 12MM
1st Tier Unifine Pentips Plus 29G X 12MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips Plus 31G X 5 MM
1st Tier Unifine Pentips Plus 31G X 5 MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips Plus 31G X 5 MM
1st Tier Unifine Pentips Plus 31G X 5 MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips Plus 31G X 6 MM
1st Tier Unifine Pentips Plus 31G X 6 MM

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
1st Tier Unifine Pentips Plus 31G X 8 MM
1st Tier Unifine Pentips Plus 31G X 8 MM

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