Choice Plan - Express Scripts

DrugNameDrugTierRequirements/Limitsprednisolone sodium phosphate 1 GC MOophthalmic solnSULFONAMIDESBLEPH-10 2 MOsodium sulfacetamide ophthalmic 1 GC MOsolnsulfacetamide sodium oint 1 GC MOSYMPATHOMIMETICSALPHAGAN P 2 MOapraclonidine 1 GC MObrimonidine tartrate 1 GC MOIOPIDINE OPHTHALMICSOLN 1%3 MOVASOCONSTRICTOR DECONGESTANTSnaphazoline hcl 1 GC MORESPIRATORY AND ALLERGYANTIHISTAMINE / ANTIALLERGENICAGENTSadrenalin inj 1 GC MOcarbinoxamine maleate 1 GC MOcetirizine hcl syrp 1 GC MOclemastine fumarate syrp 1 GC MOclemastine fumarate tabs 2.68mg 1 GC MOdesloratadine 1 GC QL(90per 90 days)MOdesloratadine odt 1 GC MOepinephrine hcl inj 0.1mg/ml 1 GC MOEPIPEN 2-PAK 2 MOEPIPEN-JR 2-PAK 2 MOhydroxyzine hcl 1 GC MOlevocetirizine dihydrochloride 1 GC MOoral solnlevocetirizine dihydrochloridetabs1 GC QL(90per 90 days)MOpalgic oral soln 1 GC MOphenadoz 1 GC MOpromethazine hcl inj 25mg/ml 1 GCpromethazine hcl inj 50mg/ml 1 GC MOpromethazine hcl supp 1 GC MOpromethazine hcl syrp 1 GC MODrugNameDrugTierRequirements/Limitspromethazine hcl tabs 1 GC MOpromethegan supp 25mg, 50mg 1 GC MOTWINJECT 2 MOPULMONARY AGENTSacetylcysteine inhalation soln 1 GC PA MOADVAIR DISKUS 2 QL(180 per90 days)MOADVAIR HFA 2 QL(36 per90 days)MOalbuterol sulfate er 1 GC MOalbuterol sulfate nebu 1 GC PA MOalbuterol sulfate syrp 1 GC MOalbuterol sulfate tabs 1 GC MOALVESCO 3 QL(37 per90 days)MOARCAPTA NEOHALER 3 QL(90 per90 days)MOASMANEX 120 METEREDDOSES2 QL(3 per 90days) MOASMANEX 14 METEREDDOSES2 QL(3 per 90days) MOASMANEX 30 METEREDDOSES2 QL(3 per 90days) MOASMANEX 60 METEREDDOSES2 QL(3 per 90days) MOATROVENT HFA 2 QL(77.4 per90 days)MObudesonide susp 1 GC PA MOCINRYZE 4 LA PAQL(60 per90 days)MOCOMBIVENT 2 QL(88.2 per90 days)MOCOMBIVENT RESPIMAT 2 QL(20 per90 days)MOcromolyn sodium nebu 1 GC PA MO37