Choice Plan - Express Scripts

DrugNameDrugTierRequirements/LimitsJANUVIA 2 QL(90 per90 days)MOJENTADUETO 2 QL(180 per90 days)MOJUVISYNC TABS 10MG;50MG, 20MG; 50MG, 40MG;2 MO50MGJUVISYNC TABS 10MG;100MG, 20MG; 100MG, 40MG;100MGKOMBIGLYZE XR TB241000MG; 5MG, 500MG; 5MGKOMBIGLYZE XR TB241000MG; 2.5MG2 QL(90 per90 days)MO2 QL(90 per90 days)MO2 QL(180 per90 days)MOLANTUS 2 QL(30 per30 days)MOLANTUS SOLOSTAR 2 QL(30 per30 days)MOLEVEMIR 2 QL(90 per90 days)MOLEVEMIR FLEXPEN 2 QL(90 per90 days)MOmetformin hcl er tb24 1000mg 1 GC QL(180per 90 days)MOmetformin hcl er tb24 750mg 1 GC QL(270per 90 days)MOmetformin hcl er tb24 500mg 1 GC QL(450per 90 days)MOmetformin hcl tabs 1000mg 1 GC QL(180per 90 days)MOmetformin hcl tabs 850mg 1 GC QL(270per 90 days)MODrugNameDrugTierRequirements/Limitsmetformin hcl tabs 500mg 1 GC QL(450per 90 days)MOnateglinide 1 GC QL(270per 90 days)MONEEDLES, INSULIN DISP., 2 MOSAFETYNOVOLOG 2 QL(60 per30 days)MONOVOLOG FLEXPEN 2 QL(60 per30 days)MONOVOLOG MIX 70/30 2 QL(60 per30 days)MONOVOLOG MIX 70/30PREFILLED FLEXPEN2 QL(60 per30 days)MOONGLYZA 2 QL(90 per90 days)MOpioglitazone hcl 1 GC QL(90per 90 days)MOpioglitazone hcl-glimepiride 1 GC QL(90per 90 days)MOpioglitazone hcl/metformin hcl 1 GC QL(270per 90 days)MOPRANDIN TABS 0.5MG, 1MG 2 QL(360 per90 days)MOPRANDIN TABS 2MG 2 QL(720 per90 days)MOPROGLYCEM 2 MOrepaglinide tabs 0.5mg, 1mg 1 GC QL(360per 90 days)MOrepaglinide tabs 2mg 1 GC QL(720per 90 days)MO28