Choice Plan - Express Scripts

DrugNameDrugTierRequirements/LimitsREMICADE 4 PA MOSANCUSO 2 QL(6 per 90days) MOSUCRAID 4 MOsulfasalazine tabs 1 GC MOsulfazine ec 1 GC MOSUPREP BOWEL PREP 2 MOTRANSDERM-SCOP 2 MOtrilyte 1 GCQL(4000per 30 days)MOUCERIS 4 MOursodiol 1 GC MOZENPEP 2 MOULCER THERAPYcarafate susp 1 GC MODEXILANT 3 QL(90 per90 days) STMOfamotidine inj 1 GC MOfamotidine premixed 1 GCfamotidine susr 1 GC MOfamotidine tabs 20mg, 40mg 1 GC MOlansoprazole 1 GC QL(180per 90 days)MOmisoprostol 1 GC MONEXIUM 2 QL(90 per90 days)MONEXIUM I.V. INJ 20MG 2NEXIUM I.V. INJ 40MG 2 MOnizatidine 1 GC MOomeprazole cpdr 40mg 1 GC QL(90per 90 days)MOomeprazole cpdr 10mg, 20mg 1 GC QL(180per 90 days)MOomeprazole/sodium bicarbonate 1 GC QL(90per 90 days)MODrugNameDrugTierRequirements/Limitspantoprazole sodium inj 1 GCpantoprazole sodium tbec 1 GC QL(180per 90 days)MOPREVPAC 3 MOPYLERA 2 MOranitidine hcl caps 1 GC MOranitidine hcl syrp 1 GC MOranitidine hcl tabs 150mg, 300mg 1 GC MOsucralfate tabs 1 GC MOZANTAC INJ 50MG/50ML;0.45%IMMUNOLOGY, VACCINES /BIOTECHNOLOGYBIOTECHNOLOGY DRUGS2 MOACTIMMUNE 4 LA MOARANESP ALBUMIN FREE 2 PA QL(3INJ 500MCG/MLper 90 days)ARANESP ALBUMIN FREEINJ 150MCG/0.3MLARANESP ALBUMIN FREEINJ 200MCG/0.4MLARANESP ALBUMIN FREEINJ 100MCG/0.5MLARANESP ALBUMIN FREEINJ 300MCG/0.6ML,60MCG/0.3MLARANESP ALBUMIN FREEINJ 40MCG/0.4MLARANESP ALBUMIN FREEINJ 25MCG/0.42MLARANESP ALBUMIN FREEINJ 100MCG/ML, 200MCG/ML,300MCG/MLARANESP ALBUMIN FREEINJ 25MCG/ML, 40MCG/ML,60MCG/MLMO2 PA QL(3.6per 90 days)MO2 PA QL(4.8per 90 days)MO2 PA QL(6per 90 days)MO2 PA QL(7.2per 90 days)MO2 PA QL(9.6per 90 days)MO2 PAQL(10.08per 90 days)MO2 PA QL(12per 90 days)MO2 PA QL(24per 90 days)MO31