All *MISCELLANEOUS THERAPEUTIC CLASSES*

azaTHIOprine Tablet 50 MG Oral
azaTHIOprine Tablet 50 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Benlysta Solution Auto-injector 200 MG/ML Subcutaneous
Benlysta Solution Auto-injector 200 MG/ML Subcutaneous

Belimumab

Tier: 4
PA Type: PA Applies
PA Group: Benlysta
Benlysta Solution Auto-injector 200 MG/ML Subcutaneous
Benlysta Solution Auto-injector 200 MG/ML Subcutaneous

Belimumab

Tier: 4
PA Type: PA Applies
PA Group: Benlysta
Benlysta Solution Auto-injector 200 MG/ML Subcutaneous
Benlysta Solution Auto-injector 200 MG/ML Subcutaneous

Belimumab

Tier: 4
PA Type: PA Applies
PA Group: Benlysta
Benlysta Solution Prefilled Syringe 200 MG/ML Subcutaneous
Benlysta Solution Prefilled Syringe 200 MG/ML Subcutaneous

Belimumab

Tier: 4
PA Type: PA Applies
PA Group: Benlysta
Benlysta Solution Prefilled Syringe 200 MG/ML Subcutaneous
Benlysta Solution Prefilled Syringe 200 MG/ML Subcutaneous

Belimumab

Tier: 4
PA Type: PA Applies
PA Group: Benlysta
Benlysta SOLUTION RECONSTITUTED 120 MG Intravenous
Benlysta SOLUTION RECONSTITUTED 120 MG Intravenous

Belimumab

Tier: 4
PA Type: PA Applies
PA Group: Benlysta
Benlysta SOLUTION RECONSTITUTED 400 MG Intravenous
Benlysta SOLUTION RECONSTITUTED 400 MG Intravenous

Belimumab

Tier: 4
PA Type: PA Applies
PA Group: Benlysta
BHI Uri-Control TABLET ORAL
BHI Uri-Control TABLET ORAL

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
CellCept CAPSULE 250 MG Oral
CellCept CAPSULE 250 MG Oral

Mycophenolate Mofetil

Tier: 3
PA Type: No Prior Authorization
ST: N
CellCept CAPSULE 250 MG Oral
CellCept CAPSULE 250 MG Oral

Mycophenolate Mofetil

Tier: 3
PA Type: No Prior Authorization
ST: N
CellCept Intravenous Solution Reconstituted 500 MG Intravenous
CellCept Intravenous Solution Reconstituted 500 MG Intravenous

Mycophenolate Mofetil HCl

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