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Lithostat - Acetohydroxamic Acid tablet
Premera
Premera Coverage for Lithostat - Acetohydroxamic Acid tablet
All
4
Commercial
3
Health Exchange
1
Commercial
Commercial - PPO
PA Required
No Step Therapy
Quantity Limit
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Commercial - Employer
PA Required
No Step Therapy
Quantity Limit
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Commercial - HMO
PA Required
No Step Therapy
Quantity Limit
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Health Exchange
Health Exchange - PPO - Health Insurance Exchange
PA Required
No Step Therapy
No Quantity Limit
See Details
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