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Ampicillin - Ampicillin capsule
University of Utah Health Plans (MCO)
University of Utah Health Plans (MCO) Coverage for Ampicillin - Ampicillin capsule
All
5
Commercial
3
Health Exchange
1
Managed Medicaid
1
Commercial
Commercial - HMO
No PA
No Step Therapy
No Quantity Limit
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Commercial - PPO
No PA
No Step Therapy
No Quantity Limit
See Details
Commercial - Employer
No PA
No Step Therapy
No Quantity Limit
See Details
Health Exchange
Health Exchange - PPO - Health Insurance Exchange
No PA
No Step Therapy
No Quantity Limit
See Details
Managed Medicaid
Managed Medicaid - HMO - Medicaid
PA Required
No Step Therapy
No Quantity Limit
See Details
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