All *RESPIRATORY AGENTS - MISC.*

Aralast NP SOLUTION RECONSTITUTED 1000 MG Intravenous
Aralast NP SOLUTION RECONSTITUTED 1000 MG Intravenous

Alpha1-Proteinase Inhibitor

Tier: 4
PA Type: PA Applies
PA Group: Alpha1 proteinase inhibitors
Aralast NP SOLUTION RECONSTITUTED 500 MG Intravenous
Aralast NP SOLUTION RECONSTITUTED 500 MG Intravenous

Alpha1-Proteinase Inhibitor

Tier: 4
PA Type: PA Applies
PA Group: Alpha1 proteinase inhibitors
Bronchitol Capsule 40 MG Inhalation
Bronchitol Capsule 40 MG Inhalation

Mannitol

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Bronchitol Capsule 40 MG Inhalation
Bronchitol Capsule 40 MG Inhalation

Mannitol

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Bronchitol Tolerance Test Capsule 40 MG Inhalation
Bronchitol Tolerance Test Capsule 40 MG Inhalation

Mannitol

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Curosurf SUSPENSION 120 MG/1.5ML Intratracheal
Curosurf SUSPENSION 120 MG/1.5ML Intratracheal

Poractant Alfa

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Curosurf SUSPENSION 240 MG/3ML Intratracheal
Curosurf SUSPENSION 240 MG/3ML Intratracheal

Poractant Alfa

Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
Esbriet CAPSULE 267 MG ORAL
Esbriet CAPSULE 267 MG ORAL

Pirfenidone

Tier: 4
PA Type: PA Applies
PA Group: Esbriet
Esbriet CAPSULE 267 MG ORAL
Esbriet CAPSULE 267 MG ORAL

Pirfenidone

Tier: 4
PA Type: PA Applies
PA Group: Esbriet
Esbriet Tablet 267 MG Oral
Esbriet Tablet 267 MG Oral

Pirfenidone

Tier: 4
PA Type: PA Applies
PA Group: Esbriet
Esbriet Tablet 267 MG Oral
Esbriet Tablet 267 MG Oral

Pirfenidone

Tier: 4
PA Type: PA Applies
PA Group: Esbriet
Esbriet Tablet 267 MG Oral
Esbriet Tablet 267 MG Oral

Pirfenidone

Tier: 4
PA Type: PA Applies
PA Group: Esbriet