Choice Plan - Express Scripts

DrugNameDrugTierRequirements/Limitsquinapril/hydrochlorothiazide 1 GC QL(90per 90 days)MOramipril 1 GC MOREMODULIN 4 PA MOreserpine 1 GC MOspironolactone 1 GC MOspironolactone/hydrochlorothiazi 1 GC MOdetaztia xt 1 GC MOTEKAMLO 2 QL(90 per90 days)MOTEKTURNA 2 QL(90 per90 days)MOTEKTURNA HCT 2 QL(90 per90 days)MOterazosin hcl 1 GC QL(180per 90 days)MOtimolol maleate 1 GC MOtorsemide tabs 1 GC MOtrandolapril 1 GC MOtriamterene/hydrochlorothiazide 1 GC MOTRIBENZOR 2 QL(90 per90 days)MOTWYNSTA 2 QL(90 per90 days)MOvalsartan/hydrochlorothiazide 1 GC QL(90per 90 days)MOverapamil hcl er 1 GC MOverapamil hcl inj 1 GCverapamil hcl sr cp24 360mg 1 GC MOverapamil hcl tabs 1 GC MOCARDIAC GLYCOSIDESdigoxin 1 GC MOLANOXIN 2 MOLANOXIN PEDIATRIC 2DrugNameDrugTierRequirements/LimitsCOAGULATION THERAPYAGGRENOX 2 MOBRILINTA 2 MOcilostazol 1 GC MOclopidogrel 1 GC MOCYKLOKAPRON 2 MOEFFIENT 2 MOELIQUIS 2 MOenoxaparin sodium inj1 GC MO300mg/3ml, 30mg/0.3ml,40mg/0.4ml, 60mg/0.6ml,80mg/0.8mlenoxaparin sodium inj 100mg/ml, 4 MO120mg/0.8ml, 150mg/mlfondaparinux sodium 1 GC MOFRAGMIN 2 MOheparin sodium inj 10000unit/ml, 1 GC MO1000unit/ml, 20000unit/ml,5000unit/mlheparin sodium/d5w inj 5%; 1 GC40unit/mlheparin sodium/nacl 0.45% 1 GCheparin sodium/sodium chloride 1 GC0.9% premixjantoven 1 GC MOLOVENOX INJ 300MG/3ML 2 MOpentoxifylline er 1 GC MOPRADAXA 2 MOPROMACTA 4 LA PAQL(90 per90 days)MOticlopidine hcl 1 GC MOwarfarin sodium 1 GC MOXARELTO 2 MOLIPID/CHOLESTEROL LOWERINGAGENTSatorvastatin calcium 1 GC QL(90per 90 days)MOcholestyramine light pack 1 GC MOcolestipol hcl 1 GC MO21