Choice Plan - Express Scripts

DrugNameDrugTierRequirements/LimitsZOVIRAX OINT 3 MOTOPICAL CORTICOSTEROIDSala cort 1 GC MOalclometasone dipropionate 1 GC MOamcinonide 1 GC MOaugmented betamethasone 1 GC MOdipropionatebetamethasone dipropionate 1 GC MObetamethasone valerate 1 GC MOCAPEX 2 MOclobetasol propionate e 1 GC MOclobetasol propionate external 1 GC MOsolnclobetasol propionate foam 1 GC MOclobetasol propionate gel 1 GC MOclobetasol propionate lotn 1 GC MOclobetasol propionate oint 1 GC MOclobetasol propionate sham 1 GC MOCORDRAN TAPE 2 MODERMA-SMOOTHE/FS BODY 2 MOOILdesonide 1 GC MOdesoximetasone 1 GC MOdiflorasone diacetate 1 GC MOfluocinolone acetonide 1 GC MOfluocinolone acetonide body 1 GC MOfluocinonide external soln 1 GC MOfluocinonide gel 1 GC MOfluocinonide oint 1 GC MOfluocinonide-e 1 GC MOfluticasone propionate 1 GC MOhalobetasol propionate 1 GC MOhydrocortisone butyrate 1 GC MOhydrocortisone crea 1%, 2.5% 1 GC MOhydrocortisone lotn 2.5% 1 GC MOhydrocortisone oint 1%, 2.5% 1 GC MOhydrocortisone valerate 1 GC MOLOCOID LOTN 2 MOLUXIQ 2 MOmometasone furoate crea 1 GC MOmometasone furoate external soln 1 GC MODrugNameDrugTierRequirements/Limitsmometasone furoate oint 1 GC MOPANDEL 2 MOprednicarbate 1 GC MOtriamcinolone acetonide crea 1 GC MOtriamcinolone acetonide lotn 1 GC MOtriamcinolone acetonide oint 1 GC MOtriderm 1 GC MOTOPICAL ENZYMESSANTYL 2 MOTOPICAL SCABICIDES / PEDICULICIDESEURAX 2 MOlindane 1 GCQL(1800per 365days) MOmalathion 1 GC MOpermethrin crea 1 GC MOSKLICE 2 MOspinosad 1 GC QL(720per 90 days)MOULESFIA 3 MODIAGNOSTICS / MISCELLANEOUSAGENTSMISCELLANEOUS AGENTSacamprosate calcium dr 1 GC QL(540per 90 days)MOACTONEL TABS 30MG 3 PA QL(60per 120days) MOADAGEN 4 LA MOalendronate sodium tabs 40mg 1 GC QL(180per 365days) MOanagrelide hydrochloride 1 GC MOANTABUSE TABS 250MG 2 MOARALAST NP INJ 400MG 4 LA MOBUPHENYL 2 MOCAMPRAL 2 QL(540 per90 days)MO24