
Amphadase Solution 150 UNIT/ML Injection
Hyaluronidase Bovine
Tier: 4
PA Type: No Prior Authorization
ST: N

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
Tacrolimus ER
Tier: 3
PA Type: No Prior Authorization
ST: N

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
Lymphocyte,Anti-Thymo Imm Glob
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
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