Choice Plan - Express Scripts

DrugNameDrugTierRequirements/Limitsbenazepril hcl 1 GC MObenazeprilhcl/hydrochlorothiazide tabs20mg; 12.5mg, 20mg; 25mgbenazeprilhcl/hydrochlorothiazide tabs10mg; 12.5mgbenazeprilhcl/hydrochlorothiazide tabs5mg; 6.25mg1 GC QL(360per 90 days)MO1 GC QL(720per 90 days)MO1 GCQL(1440per 90 days)MOBENICAR HCT 2 QL(90 per90 days)MOBENICAR TABS 20MG, 40MG 2 QL(90 per90 days)MOBENICAR TABS 5MG 2 QL(180 per90 days)MObetaxolol hcl 1 GC MOBIDIL 2 QL(540 per90 days)MObisoprolol fumarate 1 GC MObisoprolol1 GC MOfumarate/hydrochlorothiazidebumetanide 1 GC MOBYSTOLIC 2 MOcandesartan cilexetil 1 GC MOcandesartan1 GC MOcilexetil/hydrochlorothiazidecaptopril 1 GC MOcaptopril/hydrochlorothiazidetabs 25mg; 15mg, 25mg; 25mg,50mg; 15mg1 GC QL(90per 90 days)MOcaptopril/hydrochlorothiazidetabs 50mg; 25mg1 GC QL(270per 90 days)MOcartia xt 1 GC MOcarvedilol 1 GC MOchlorothiazide 1 GC MOchlorothiazide sodium 1 GC MOchlorthalidone tabs 25mg, 50mg 1 GC MODrugNameDrugTierRequirements/Limitsclonidine hcl ptwk 1 GC MOclonidine hcl tabs 1 GC MOCOREG CR 2 MODEMSER 2 MODIBENZYLINE 3 MOdilt-cd cp24 120mg, 300mg 1 GC MOdilt-xr cp24 180mg, 240mg 1 GC MOdiltiazem cd cp24 120mg, 240mg, 1 GC MO300mgdiltiazem hcl er cp12 1 GC MOdiltiazem hcl er cp24 180mg, 1 GC MO360mg, 420mgdiltiazem hcl inj 100mg,1 GC50mg/10mldiltiazem hcl tabs 1 GC MODIOVAN HCT 3 QL(90 per90 days)MODIOVAN TABS 320MG 2 QL(90 per90 days)MODIOVAN TABS 160MG, 40MG,80MG2 QL(180 per90 days)MOdoxazosin mesylate 1 GC QL(180per 90 days)MOEDECRIN 2 MOenalapril maleate 1 GC MOenalaprilmaleate/hydrochlorothiazide tabs5mg; 12.5mgenalaprilmaleate/hydrochlorothiazide tabs10mg; 25mg1 GC QL(90per 90 days)MO1 GC QL(180per 90 days)MOeplerenone 1 GC MOeprosartan mesylate 1 GC QL(90per 90 days)MOEXFORGE 2 QL(90 per90 days)MOEXFORGE HCT 2 QL(90 per90 days)MO19