Choice Plan - Express Scripts

DrugNameDrugTierRequirements/LimitsXOPENEX HFA 2 QL(90 per90 days)MOzafirlukast 1 GC QL(180per 90 days)MOZYFLO 3 QL(360 per90 days)MOZYFLO CR 3 QL(360 per90 days)MOUROLOGICALSANTICHOLINERGICS /ANTISPASMODICSDETROL LA 2 QL(90 per90 days)MOENABLEX 2 QL(90 per90 days)MOflavoxate hcl 1 GC MOGELNIQUE GEL 10% 2 QL(90 per90 days)MOGELNIQUE GEL 3% 2 QL(276 per90 days)MOMYRBETRIQ 2 QL(90 per90 days)MOoxybutynin chloride er tb24 5mg 1 GC QL(90per 90 days)MOoxybutynin chloride er tb24 10mg,15mg1 GC QL(180per 90 days)MOoxybutynin chloride syrp 1 GC MOoxybutynin chloride tabs 1 GC QL(360per 90 days)MOOXYTROL 2 QL(32 per90 days)MODrugNameDrugTierRequirements/LimitsSANCTURA XR 3 QL(90 per90 days)MOtolterodine tartrate 1 GC QL(180per 90 days)MOTOVIAZ 2 QL(90 per90 days)MOtrospium chloride 1 GC QL(180per 90 days)MOtrospium chloride er 1 GC QL(90per 90 days)MOVESICARE 2 QL(90 per90 days)MOBENIGN PROSTATICHYPERPLASIA(BPH) THERAPYalfuzosin hcl er 1 GC QL(90per 90 days)MOAVODART 2 QL(90 per90 days)MOfinasteride tabs 5mg 1 GC QL(90per 90 days)MOJALYN 2 QL(90 per90 days)MORAPAFLO 2 QL(90 per90 days)MOtamsulosin hcl 1 GC QL(180per 90 days)MOUROXATRAL 2 QL(90 per90 days)MOCHOLINERGIC STIMULANTSbethanechol chloride 1 GC MOMISCELLANEOUS UROLOGICALS39