Choice Plan - Express Scripts

DrugNameDrugTierRequirements/Limitsenpresse-28 1 GC MOgianvi 1 GC MOgildagia 1 GC MOintrovale 1 GC MOjunel 1.5/30 1 GC MOjunel 1/20 1 GC MOjunel fe 1.5/30 1 GC MOjunel fe 1/20 1 GC MOkariva 1 GC MOkelnor 1/35 1 GC MOleena 1 GC MOlessina 1 GC MOlevonest 1 GC MOlevonorgestrel/ethinyl estradiol 1 GC MOtabs 0.03mg; 0.15mglevora 0.15/30-28 1 GC MOloryna 1 GC MOlow-ogestrel 1 GC MOlutera 1 GC MOmarlissa 1 GC MOmicrogestin 1.5/30 1 GC MOmicrogestin 1/20 1 GC MOmicrogestin fe 1 GC MOmicrogestin fe 1.5/30 1 GC MOmononessa 1 GC MOnecon 0.5/35-28 1 GC MOnecon 1/35 1 GC MOnecon 10/11-28 1 GC MOnecon 7/7/7 1 GC MOnortrel 0.5/35 (28) 1 GC MOnortrel 1/35 1 GC MOnortrel 7/7/7 1 GC MOocella 1 GC MOogestrel 1 GC MOorsythia 1 GC MOpirmella 1/35 1 GC MOportia-28 1 GC MOprevifem 1 GC MOquasense 1 GC MOreclipsen 1 GC MOsprintec 28 1 GC MODrugNameDrugTierRequirements/Limitssronyx 1 GC MOtri-legest fe 1 GC MOtri-previfem 1 GC MOtri-sprintec 1 GC MOtrinessa 1 GC MOtrivora-28 1 GC MOvelivet 1 GC MOvestura 1 GC MOzenchent fe 1 GC MOzeosa 1 GC MOzovia 1/35e 1 GC MOzovia 1/50e 1 GC MOOXYTOCICSMETHERGINE 2 MOmethylergonovine maleate tabs 1 GC MOOPHTHALMOLOGYANTIBIOTICSAZASITE 2 MObacitracin ophthalmic oint 1 GC MObacitracin/polymyxin b 1 GC MOBESIVANCE 2 MOCILOXAN OINT 2 MOciprofloxacin hcl 1 GC MOerythromycin oint 1 GC MOgentak oint 1 GC MOgentamicin sulfate ophthalmic 1 GC MOsolnlevofloxacin 1 GC MOMOXEZA 2 MONATACYN 2 MOneomycin/bacitracin/polymyxin 1 GC MOneomycin/polymyxin/gramicidin 1 GC MOofloxacin 1 GC MOtobramycin sulfate ophthalmic 1 GC MOsolnTOBREX OINT 2 MOtrimethoprim sulfate/polymyxin b 1 GC MOsulfateVIGAMOX 2 MOZYMAXID 2 MOANTIVIRALS35