All *PASSIVE IMMUNIZING AND TREATMENT AGENTS*

Anascorp SOLUTION RECONSTITUTED Intravenous
Anascorp SOLUTION RECONSTITUTED Intravenous

Centruroides (Scorpion) Im Fab

Tier: 3
PA Type: No Prior Authorization
ST: N
Anavip Solution Reconstituted Intravenous
Anavip Solution Reconstituted Intravenous

Crotalidae Immune Fab (Equine)

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Anavip Solution Reconstituted Intravenous
Anavip Solution Reconstituted Intravenous

Crotalidae Immune Fab (Equine)

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Antivenin Latrodectus Mactans Kit Injection
Antivenin Latrodectus Mactans Kit Injection

Tier: 3
PA Type: No Prior Authorization
ST: N
Antivenin Micrurus Fulvius SOLUTION RECONSTITUTED Intravenous
Antivenin Micrurus Fulvius SOLUTION RECONSTITUTED Intravenous

Tier: 3
PA Type: No Prior Authorization
ST: N
Antivenin Micrurus Fulvius SOLUTION RECONSTITUTED Intravenous
Antivenin Micrurus Fulvius SOLUTION RECONSTITUTED Intravenous

Tier: 3
PA Type: No Prior Authorization
ST: N
Asceniv Solution 5 GM/50ML Intravenous
Asceniv Solution 5 GM/50ML Intravenous

Immune Globulin (Human)-slra

Tier: Non-Formulary
PA Type: PA Applies
PA Group: Immunoglobulins
Asceniv Solution 5 GM/50ML Intravenous
Asceniv Solution 5 GM/50ML Intravenous

Immune Globulin (Human)-slra

Tier: Non-Formulary
PA Type: PA Applies
PA Group: Immunoglobulins
Bamlanivimab Solution 700 MG/20ML Intravenous
Bamlanivimab Solution 700 MG/20ML Intravenous

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Bivigam Solution 5 GM/50ML Intravenous
Bivigam Solution 5 GM/50ML Intravenous

Immune Globulin (Human)

Tier: 4
PA Type: PA Applies
PA Group: Immunoglobulins
Bivigam Solution 5 GM/50ML Intravenous
Bivigam Solution 5 GM/50ML Intravenous

Immune Globulin (Human)

Tier: 4
PA Type: PA Applies
PA Group: Immunoglobulins
Bivigam Solution 5 GM/50ML Intravenous
Bivigam Solution 5 GM/50ML Intravenous

Immune Globulin (Human)

Tier: 4
PA Type: PA Applies
PA Group: Immunoglobulins