Choice Plan - Express Scripts

DrugNamehydrocodonebitartrate/acetaminophen tabs300mg; 10mg, 300mg; 5mg,300mg; 7.5mghydrocodone/acetaminophen oralsolnhydrocodone/acetaminophen tabs750mg; 7.5mghydrocodone/acetaminophen tabs650mg; 10mg, 650mg; 7.5mg,660mg; 10mghydrocodone/acetaminophen tabs500mg; 10mg, 500mg; 2.5mg,500mg; 5mg, 500mg; 7.5mghydrocodone/acetaminophen tabs325mg; 10mg, 325mg; 5mg,325mg; 7.5mgDrugTierRequirements/Limits1 GCQL(1080per 90 days)MO1 GCQL(3600per 30 days)MO1 GC QL(450per 90 days)MO1 GC QL(540per 90 days)MO1 GC QL(720per 90 days)MO1 GCQL(1080per 90 days)MOhydrocodone/ibuprofen tabs 1 GC MO7.5mg; 200mghydromorphone hcl inj2500mg/50mlhydromorphone hcl tabs 1 GC MOLAZANDA 4 LA PAQL(31 per90 days)MOlevorphanol tartrate 1 GC MOmethadone hcl conc 1 GC MOmethadone hcl inj 1 GCmethadone hcl oral soln 1 GC MOmethadone hcl tabs 1 GC MOmethadose tabs 1 GC MOmorphine sulfate er cp24 10mg 1 GCmorphine sulfate er cp24 100mg, 1 GC MO20mg, 30mg, 50mg, 60mg, 80mgmorphine sulfate er tbcr 1 GC MOmorphine sulfate oral soln 1 GC MOmorphine sulfate tabs 1 GC MOONSOLIS FILM 1200MCG,400MCG, 600MCG, 800MCG2 PA QL(360per 90 days)MODrugNameDrugTierRequirements/LimitsONSOLIS FILM 200MCG 2 PA QL(720per 90 days)MOOPANA ER (CRUSHRESISTANT)2 QL(540 per90 days)MOoxycodone hcl caps 1 GCQL(1080per 90 days)MOoxycodone hcl conc 1 GCQL(1800per 90 days)MOoxycodone hcl oral soln 1 GCQL(3600per 90 days)MOoxycodone hcl tabs 10mg, 15mg,20mg, 30mg1 GC QL(540per 90 days)MOoxycodone hcl tabs 5mg 1 GCQL(1080per 90 days)MOoxycodone/acetaminophen caps 1 GC QL(720per 90 days)MOoxycodone/acetaminophen tabs650mg; 10mgoxycodone/acetaminophen tabs500mg; 7.5mgoxycodone/acetaminophen tabs325mg; 10mg, 325mg; 2.5mg,325mg; 5mg, 325mg; 7.5mg1 GC QL(540per 90 days)MO1 GC QL(720per 90 days)MO1 GCQL(1080per 90 days)MOoxycodone/aspirin 1 GC MOOXYCONTIN 2 QL(540 per90 days)MOoxymorphone hydrochloride 1 GC MOoxymorphone hydrochloride er 1 GC MOtb12 15mg, 7.5mgreprexain tabs 10mg; 200mg 1 GC MO13