
Aquasol A Solution 50000 UNIT/ML Intramuscular
Vitamin A
Tier: 3
PA Type: No Prior Authorization
ST: N

Ascor Solution 25000 MG/50ML Intravenous
Ascorbic Acid
Tier: 3
PA Type: No Prior Authorization
ST: N

Ascor Solution 25000 MG/50ML Intravenous
Ascorbic Acid
Tier: 3
PA Type: No Prior Authorization
ST: N

Ascorbic Acid Solution 15000 MG/30ML Intravenous
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N

Ascorbic Acid Solution 15000 MG/30ML Intravenous
Tier: Non-Formulary
PA Type: No Prior Authorization
ST: N
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