Choice Plan - Express Scripts

DrugNameDrugTierRequirements/Limitsimiquimod 1 GC MOlaclotion 1 GC MOOXSORALEN ULTRA 4 MOPANRETIN 2 MOpodofilox 1 GC MOPROTOPIC 3 MOprudoxin 1 GC MOREGRANEX 2 PA MOSOLARAZE 3 MOUVADEX 3VEREGEN 3 MOTHERAPY FOR ACNEadapalene 1 GC MOamnesteem 1 GC MOavita crea 1 GC MOAZELEX 2 MOclaravis caps 10mg, 20mg, 40mg 2 MOclaravis caps 30mg 4 MOclindamycin phosphate external 1 GC MOsolnclindamycin phosphate foam 1 GC MOclindamycin phosphate gel 1 GC MOclindamycin phosphate lotn 1 GC MOclindamycin phosphate swab 1 GC MOclindamycin/benzoyl peroxide gel 1 GC MO5%; 1%DIFFERIN GEL 0.3% 2 MODIFFERIN LOTN 2 MOery 1 GC MOerythromycin external soln 1 GC MOerythromycin gel 1 GC MOerythromycin/benzoyl peroxide 1 GC MOFINACEA 2 MOMETROGEL 2 MOmetronidazole 1 GC MOmyorisan 1 GC MOTAZORAC 2 MOtretinoin 1 GC MOTOPICAL ANESTHETICSlidocaine hcl external soln 1 GC MOlidocaine hcl inj 0.5%, 1% 1 GC MODrugNameDrugTierRequirements/Limitslidocaine hcl jelly 1 GC MOlidocaine oint 1 GC MOlidocaine viscous 1 GC MOlidocaine/prilocaine crea 1 GC MOLIDODERM 2 PA MOTOPICAL ANTIBACTERIALSALTABAX 2 MOBACTROBAN CREA 2 MOgentamicin sulfate crea 1 GC MOgentamicin sulfate oint 0.1% 1 GC MOmafenide acetate 1 GC MOmupirocin 1 GC MOPHISOHEX 2 MOsulfacetamide sodium susp 1 GC MOSULFAMYLON 2 MOTOPICAL ANTIFUNGALSciclopirox 1 GC MOciclopirox nail lacquer 1 GC MOciclopirox olamine 1 GC MOclotrimazole external crea 1 GC MOclotrimazole external soln 1 GC MOclotrimazole/betamethasone 1 GC MOdipropionateeconazole nitrate 1 GC MOketoconazole 1 GC MOketodan kit 1 GC MONAFTIN CREA 1% 2 MONAFTIN GEL 2% 2NAFTIN GEL 1% 2 MOnyamyc 1 GC MOnystatin crea 1 GC MOnystatin oint 1 GC MOnystatin powd 100000unit/gm 1 GC MOnystatin/triamcinolone 1 GC MOnystop 1 GC MOpedi-dri 1 GC MOTOPICAL ANTIVIRALSacyclovir 1 GC MODENAVIR 2 MOZOVIRAX CREA 3 MO23