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DrugNameDrugTierRequirements/LimitsHAVRIX INJ 1440ELU/ML 2 MOIMOVAX RABIES (H.D.C.V.) 2 MOINFANRIX 2IPOL INACTIVATED IPV 2 MOIXIARO 2 MOM-M-R II W/DILUENT 10 2 MODOSEMENACTRA 2 MOMENOMUNE-A/C/Y/W-135 2 MOMENVEO 2 MOPEDVAX HIB 2 MOPRIVIGEN INJ 20GM/200ML 4 PA MOPROQUAD 2RABAVERT 2 MORECOMBIVAX HB INJ2 PA MO10MCG/ML, 40MCG/MLROTATEQ 2tetanus toxoid adsorbed 1 GC MOTETANUS/DIPHTHERIA 2 MOTOXOIDS-ADSORBED ADULTTHYMOGLOBULIN 2TWINRIX 2 MOTYPHIM VI 2VAQTA INJ 25UNIT/0.5ML 2 MOVARIVAX 2 MOYF-VAX 2 MOZOSTAVAX 2 PA MOMUSCULOSKELETAL /RHEUMATOLOGYGOUT THERAPYallopurinol 1 GC MOCOLCRYS 2 QL(360 per90 days)MOprobenecid 1 GC MOprobenecid/colchicine 1 GC MOULORIC 2 MOOSTEOPOROSIS THERAPYACTONEL TABS 150MG 2 QL(3 per 90days) MODrugNameDrugTierRequirements/LimitsACTONEL TABS 35MG 2 QL(12 per90 days)MOACTONEL TABS 5MG 2 QL(90 per90 days)MOalendronate sodium oral soln 1 GC MOalendronate sodium tabs 35mg,70mgalendronate sodium tabs 10mg,5mg1 GC QL(12per 90 days)MO1 GC QL(90per 90 days)MOATELVIA 2 QL(12 per90 days)MOEVISTA 2 QL(90 per90 days)MOFORTEO 2 QL(7.2 per90 days)MOFOSAMAX PLUS D 3 ST MOibandronate sodium 1 GC MOPROLIA 3 ST MOOTHER RHEUMATOLOGICALSDEPEN TITRATABS 2 MOENBREL 4 PA QL(600per 90 days)MOHUMIRA INJ 20MG/0.4ML 4 PA QL(2.4per 90 days)MOHUMIRA INJ 40MG/0.8ML 4 PA QL(4.8per 90 days)MOHUMIRA PEN-CROHNS 4 PA MODISEASESTARTERleflunomide tabs 10mg 1 GC QL(90per 90 days)MOleflunomide tabs 20mg 1 GC QL(102per 90 days)MO33
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