Choice Plan - Express Scripts

DrugNameDrugTierRequirements/Limitsampicillin 1 GC MOampicillin sodium inj 1gm 1 GCampicillin sodium inj 10gm, 1 GC MO125mgampicillin-sulbactam inj 10gm; 1 GC5gmampicillin-sulbactam inj 2gm; 1 GC MO1gmBICILLIN C-R 2 MOBICILLIN L-A 2 MOdicloxacillin sodium 1 GC MOnafcillin sodium inj 10gm, 1gm 1 GC MOnallpen/dextrose 1 GCPENICILLIN G POTASSIUM IN 2ISO-OSMOTIC DEXTROSE INJ0; 40000UNIT/ML, 0;60000UNIT/MLpenicillin g potassium inj 5mu 1 GC MOpenicillin g procaine 1 GC MOpenicillin g sodium 1 GC MOpenicillin v potassium 1 GC MOpfizerpen-g inj 20mu 1 GC MOpiperacillin sodium/tazobactam 1 GC MOsodium inj 3gm; 0.375gm, 4gm;0.5gmZOSYN INJ 5%; 2GM/50ML; 20.25GM/50MLZOSYN INJ 5%; 3GM/50ML; 2 MO0.375GM/50MLQUINOLONESAVELOX 2 MOAVELOX ABC PACK 2 MOCIPRO I.V.-IN D5W INJ 2200MG/100ML; 5%ciprofloxacin hcl 1 GC MOciprofloxacin i.v.-in d5w inj 1 GC MO200mg/100ml; 5%ciprofloxacin inj 400mg/40ml 1 GClevofloxacin 1 GC MOlevofloxacin in d5w inj 5%; 1 GC500mg/100mlNOROXIN 3 MOofloxacin 1 GC MODrugNameDrugTierRequirements/LimitsSULFA'S / RELATED AGENTSsulfadiazine 1 GC MOsulfamethoxazole/trimethoprim 1 GC MOsulfamethoxazole/trimethoprim ds 1 GC MOTETRACYCLINESdemeclocycline hcl 2 MOdoxycycline hyclate caps 1 GC MOdoxycycline hyclate dr 1 GC MOdoxycycline hyclate inj 1 GC MOdoxycycline hyclate tabs 1 GC MOdoxycycline monohydrate caps 1 GC MO75mgdoxycycline monohydrate susr 1 GC MOdoxycycline monohydrate tabs 1 GC MO150mg, 50mg, 75mgminocycline hcl 1 GC MOminocycline hcl er 1 GC MOtetracycline hcl 1 GC MOVIBRAMYCIN SUSR 2 MOVIBRAMYCIN SYRP 2 MOURINARY TRACT AGENTSMACRODANTIN CAPS 25MG 2 MOmethenamine hippurate 1 GC MOnitrofurantoin macrocrystalline 1 GC MOcaps 50mgnitrofurantoin monohydrate 1 GC MOnitrofurantoin susp 1 GC MOPRIMSOL 3 MOtrimethoprim 1 GC MOVANCOMYCINvancomycin hcl caps 1 GC MOvancomycin hcl inj 500mg 1 GC PAvancomycin hcl inj 1000mg, 10gm 1 GC PA MOVIBATIV INJ 250MG 2ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSADJUNCTIVE AGENTSamifostine 4 MOdexrazoxane inj 500mg 1 GC MOELITEK INJ 1.5MG 46