All *MISCELLANEOUS THERAPEUTIC CLASSES*

Acunol Tablet Oral
Acunol Tablet Oral

Homeopathic Products

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Alprostadil Solution 500 MCG/ML Injection
Alprostadil Solution 500 MCG/ML Injection

Tier: 1
PA Type: No Prior Authorization
ST: N
Alprostadil Solution 500 MCG/ML Injection
Alprostadil Solution 500 MCG/ML Injection

Tier: 1
PA Type: No Prior Authorization
ST: N
Amphadase Solution 150 UNIT/ML Injection
Amphadase Solution 150 UNIT/ML Injection

Hyaluronidase Bovine

Tier: 4
PA Type: No Prior Authorization
ST: N
Asclera SOLUTION 0.5 % Intravenous
Asclera SOLUTION 0.5 % Intravenous

Polidocanol

Tier: 3
PA Type: No Prior Authorization
ST: N
Asclera SOLUTION 1 % Intravenous
Asclera SOLUTION 1 % Intravenous

Polidocanol

Tier: 3
PA Type: No Prior Authorization
ST: N
Astagraf XL Capsule Extended Release 24 Hour 0.5 MG Oral
Astagraf XL Capsule Extended Release 24 Hour 0.5 MG Oral

Tacrolimus ER

Tier: 3
PA Type: No Prior Authorization
ST: N
Astagraf XL Capsule Extended Release 24 Hour 1 MG Oral
Astagraf XL Capsule Extended Release 24 Hour 1 MG Oral

Tacrolimus ER

Tier: 3
PA Type: No Prior Authorization
ST: N
Astagraf XL Capsule Extended Release 24 Hour 5 MG Oral
Astagraf XL Capsule Extended Release 24 Hour 5 MG Oral

Tacrolimus ER

Tier: 3
PA Type: No Prior Authorization
ST: N
Atgam INJECTABLE 50 MG/ML Intravenous
Atgam INJECTABLE 50 MG/ML Intravenous

Lymphocyte,Anti-Thymo Imm Glob

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Atgam INJECTABLE 50 MG/ML Intravenous
Atgam INJECTABLE 50 MG/ML Intravenous

Lymphocyte,Anti-Thymo Imm Glob

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

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