All *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*

Acamprosate Calcium Tablet Delayed Release 333 MG Oral
Acamprosate Calcium Tablet Delayed Release 333 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Acamprosate Calcium Tablet Delayed Release 333 MG Oral
Acamprosate Calcium Tablet Delayed Release 333 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Acamprosate Calcium Tablet Delayed Release 333 MG Oral
Acamprosate Calcium Tablet Delayed Release 333 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Acamprosate Calcium Tablet Delayed Release 333 MG Oral
Acamprosate Calcium Tablet Delayed Release 333 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Acamprosate Calcium Tablet Delayed Release 333 MG Oral
Acamprosate Calcium Tablet Delayed Release 333 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Acamprosate Calcium Tablet Delayed Release 333 MG Oral
Acamprosate Calcium Tablet Delayed Release 333 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Acamprosate Calcium Tablet Delayed Release 333 MG Oral
Acamprosate Calcium Tablet Delayed Release 333 MG Oral

Tier: 1
PA Type: No Prior Authorization
ST: N
Addyi TABLET 100 MG ORAL
Addyi TABLET 100 MG ORAL

Flibanserin

Tier: 3
PA Type: No Prior Authorization
ST: N
Ampyra Tablet Extended Release 12 Hour 10 MG Oral
Ampyra Tablet Extended Release 12 Hour 10 MG Oral

Dalfampridine ER

Tier: 4
PA Type: PA Applies
PA Group: Ampyra
Antabuse Tablet 250 MG Oral
Antabuse Tablet 250 MG Oral

Disulfiram

Tier: 3
PA Type: No Prior Authorization
ST: N
Antabuse Tablet 500 MG Oral
Antabuse Tablet 500 MG Oral

Disulfiram

Tier: 3
PA Type: No Prior Authorization
ST: N
Aricept Tablet 10 MG Oral
Aricept Tablet 10 MG Oral

Donepezil HCl

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