Choice Plan - Express Scripts

DrugNameDrugTierRequirements/LimitsABILIFY MAINTENA INJ 4 MO300MGABILIFY ORAL SOLN 3 MOABILIFY TABS 20MG, 2MG,30MG, 5MG3 QL(90 per90 days)MOABILIFY TABS 15MG 3 QL(180 per90 days)MOABILIFY TABS 10MG 3 QL(270 per90 days)MOamitriptyline hcl 1 GC MOamoxapine 1 GC MObudeprion sr 1 GC QL(180per 90 days)MObupropion hcl 1 GC MObupropion hcl sr 1 GC QL(180per 90 days)MObupropion hcl xl tb24 300mg 1 GC QL(90per 90 days)MObupropion hcl xl tb24 150mg 1 GC QL(270per 90 days)MObuspirone hcl 1 GC MOchlordiazepoxide/amitriptyline 1 GC MOchlorpromazine hcl inj 1 GC MOchlorpromazine hcl tabs 1 GC MOcitalopram hydrobromide oralsolncitalopram hydrobromide tabs40mgcitalopram hydrobromide tabs10mgcitalopram hydrobromide tabs20mg1 GC MO1 GC QL(90per 90 days)MO1 GC QL(180per 90 days)MO1 GC QL(270per 90 days)MOclomipramine hcl 1 GC MOclorazepate dipotassium 1 GC MOclozapine 1 GCDrugNameDrugTierRequirements/LimitsCYMBALTA CPEP 60MG 2 QL(180 per90 days)MOCYMBALTA CPEP 30MG 2 QL(360 per90 days)MOCYMBALTA CPEP 20MG 2 QL(540 per90 days)MOdesipramine hcl 1 GC MOdextroamphetamine sulfate er 1 GC PA MOdextroamphetamine sulfate tabs 1 GC PA MOdiazepam intensol 1 GC MOdiazepam oral soln 1 GC MOdiazepam tabs 1 GC MOdoxepin hcl 1 GC MOEMSAM 3 QL(90 per90 days)MOescitalopram oxalate oral soln 1 GCQL(1920per 90 days)MOescitalopram oxalate tabs 1 GC QL(90per 90 days)MOFANAPT TABS 1MG, 2MG,4MGFANAPT TABS 10MG, 12MG,6MG, 8MG3 QL(90 per90 days)MO3 QL(180 per90 days)MOFANAPT TITRATION PACK 3FAZACLO 3fluoxetine dr 1 GC QL(12per 90 days)MOfluoxetine hcl caps 40mg 1 GC QL(180per 90 days)MOfluoxetine hcl caps 20mg 1 GC QL(360per 90 days)MO15