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DrugNameDrugTierRequirements/LimitsFUSILEV 4 MOleucovorin calcium inj 100mg, 1 GC MO350mgleucovorin calcium tabs 1 GC MOmesna 1 GC MOMESNEX TABS 2 MOXGEVA 4 PA QL(8.5per 90 days)MOZINECARD INJ 250MG 2 MOANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSABRAXANE 3 MOadriamycin inj 2mg/ml 1 GC MOAFINITOR DISPERZ 4 PA QL(360per 90 days)MOAFINITOR TABS 10MG, 7.5MG 4 PA QL(180per 90 days)MOAFINITOR TABS 2.5MG, 5MG 4 PA QL(270per 90 days)MOALIMTA INJ 500MG 3 MOALKERAN INJ 3anastrozole 1 GC MOARRANON 3ARZERRA INJ 100MG/5ML 2 MOAVASTIN INJ 100MG/4ML 3 MOazathioprine 1 GC PA MOazathioprine sodium 1 GC MObicalutamide 1 GC MOBICNU 3 MObleomycin sulfate inj 30unit 1 GC MOBOSULIF TABS 500MG 4 PA QL(90per 90 days)MOBOSULIF TABS 100MG 4 PA QL(360per 90 days)MOBUSULFEX 2CAMPATH 3 MODrugNameDrugTierRequirements/LimitsCAPRELSA TABS 300MG 4 QL(90 per90 days)MOCAPRELSA TABS 100MG 4 QL(180 per90 days)MOcarboplatin inj 150mg/15ml 1 GC MOCEENU 2 MOCELLCEPT INTRAVENOUS 2CELLCEPT SUSR 2 PA MOcisplatin inj 100mg/100ml 1 GC MOcladribine 1 GC MOCLOLAR 3 MOCOMETRIQ 4 PA MOCOSMEGEN 3 MOcyclophosphamide tabs 1 GC PA MOcyclosporine caps 1 GC PA MOcyclosporine inj 1 GCcyclosporine modified 1 GC PA MOcytarabine aqueous 1 GC MOcytarabine inj 500mg 1 GC MOdacarbazine inj 200mg 1 GC MODACOGEN 2 MOdaunorubicin hcl inj 5mg/ml 1 GCdecitabine 4 MODOCEFREZ 4docetaxel inj 80mg/8ml 1 GCdocetaxel inj 80mg/4ml 1 GC MODOXIL 2 MOdoxorubicin hcl inj 2mg/ml 1 GC MODROXIA 2 MOELLENCE INJ 200MG/100ML 3 MOELOXATIN INJ 100MG/20ML 3 MOELSPAR 3 MOEMCYT 2 MOepirubicin hcl inj 50mg/25ml 1 GC MOERBITUX INJ 100MG/50ML 3 MOERIVEDGE 4 PA MOETOPOPHOS 3 MOetoposide inj 500mg/25ml 1 GC MOexemestane 1 GC MO7
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