Choice Plan - Express Scripts

DrugNameDrugTierRequirements/LimitsVOTRIENT 4 QL(360 per90 days)MOXALKORI 4 PA QL(180per 90 days)MOXTANDI 4 PA QL(360per 90 days)MOYERVOY INJ 50MG/10ML 4 PA MOZALTRAP INJ 100MG/4ML 4 PA MOZANOSAR 3 MOZELBORAF 4 PA QL(720per 90 days)MOZOLINZA 4 QL(360 per90 days)MOZORTRESS TABS 0.5MG, 4 PA MO0.75MGZORTRESS TABS 0.25MG 2 PA MOZYTIGA 4 PA QL(360per 90 days)MOAUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCHANTICONVULSANTSBANZEL 2 MOcarbamazepine 1 GC MOcarbamazepine er 1 GC MOCARBATROL 2 MOCELONTIN 2 MOclonazepam 1 GC MOclonazepam odt 1 GC MOdiazepam gel 1 GC MODILANTIN CAPS 30MG 2 MODILANTIN INFATABS 2 MOdivalproex sodium 1 GC MOdivalproex sodium dr 1 GC MOdivalproex sodium er 1 GC MOepitol 1 GC MOethosuximide 1 GC MOfelbamate 1 GC MODrugNameDrugTierRequirements/LimitsFELBATOL 2 MOfosphenytoin sodium inj 100mg 1 GC MOpe/2mlgabapentin 1 GC MOGABITRIL 2 MOLAMICTAL ODT TBDP 2 MOLAMICTAL STARTER/NOT 2 MOTAKING CARBAMAZEPINELAMICTAL2 MOSTARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATELAMICTAL2 MOSTARTER/TAKINGVALPROATELAMICTAL XR 2 MOlamotrigine 1 GC MOlamotrigine er 1 GC MOlevetiracetam er 1 GC MOlevetiracetam inj 500mg/5ml 1 GC MOlevetiracetam oral soln 1 GC MOlevetiracetam tabs 1 GC MOLYRICA CAPS 225MG, 300MG 2 QL(180 per90 days)MOLYRICA CAPS 100MG, 150MG,200MG, 25MG, 50MG, 75MG2 QL(270 per90 days)MOLYRICA ORAL SOLN 2 QL(2880per 90 days)MOONFI 2 MOoxcarbazepine 1 GC MOPEGANONE 2 MOphenobarbital 1 GC PA MOphenytoin 1 GC MOphenytoin sodium 1 GCphenytoin sodium extended 1 GC MOPOTIGA 3 MOprimidone 1 GC MOSABRIL 2 MOTEGRETOL-XR TB12 100MG 2 MOtiagabine hydrochloride 1 GC MO10