Choice Plan - Express Scripts

DrugNameDrugTierRequirements/Limitsfluoxetine hcl caps 10mg 1 GC QL(720per 90 days)MOfluoxetine hcl oral soln 1 GC MOfluoxetine hcl tabs 20mg 1 GC QL(360per 90 days)MOfluoxetine hcl tabs 10mg 1 GC QL(720per 90 days)MOfluphenazine decanoate 1 GC MOfluphenazine hcl conc 1 GCfluphenazine hcl elix 1 GC MOfluphenazine hcl inj 1 GC MOfluphenazine hcl tabs 1 GC MOfluvoxamine maleate 1 GC QL(270per 90 days)MOfluvoxamine maleate er cp24150mgfluvoxamine maleate er cp24100mg1 GC QL(180per 90 days)MO1 GC QL(270per 90 days)MOFOCALIN XR 2 PA MOFORFIVO XL 3 QL(90 per90 days)MOGEODON INJ 3 MOHALDOL 2 MOHALDOL DECANOATE 100 2 MOHALDOL DECANOATE 50 2 MOhaloperidol 1 GC MOhaloperidol decanoate 1 GC MOhaloperidol lactate 1 GC MOimipramine hcl 1 GC MOimipramine pamoate 2 MOINTUNIV 3 MOINVEGA SUSTENNA INJ39MG/0.25MLINVEGA SUSTENNA INJ78MG/0.5ML2 QL(0.75 per90 days)MO2 QL(1.5 per90 days)MODrugNameINVEGA SUSTENNA INJ117MG/0.75MLINVEGA SUSTENNA INJ156MG/MLINVEGA SUSTENNA INJ234MG/1.5MLINVEGA TB24 1.5MG, 3MG,9MGDrugTierRequirements/Limits2 QL(2.25 per90 days)MO2 QL(3 per 90days) MO2 QL(4.5 per90 days)MO3 QL(90 per90 days)MOINVEGA TB24 6MG 3 QL(180 per90 days)MOLATUDA TABS 120MG 2 QL(90 per90 days)MOLATUDA TABS 80MG 2 QL(180 per90 days)MOLATUDA TABS 40MG 2 QL(360 per90 days)MOLATUDA TABS 20MG 2 QL(720 per90 days)MOlithium carbonate 1 GC MOlithium carbonate er 1 GC MOlithium citrate 1 GC MOlorazepam intensol 1 GC MOlorazepam tabs 1 GC MOloxapine succinate 1 GC MOLUNESTA 3 QL(90 per90 days)MOmaprotiline hcl 1 GC MOMARPLAN 2 MOMETADATE CD CPCR 20MG, 3 PA MO30MG, 40MG, 50MG, 60MGmethylphenidate hcl 1 GC PA MOmethylphenidate hcl cd cpcr 1 GC PA MO50mg, 60mgmethylphenidate hcl er cp24 1 GC PA MOmethylphenidate hydrochloride 1 GC PA MO16