Choice Plan - Express Scripts

DrugNameDrugTierRequirements/LimitsCIALIS TABS 2.5MG, 5MG 2 PA QL(90per 90 days)MOCYSTAGON 2 LA MOELMIRON 2 MOpotassium citrate tbcr 1 GC MOVITAMINS, HEMATINICS /ELECTROLYTESELECTROLYTEScalcium acetate caps 1 GC MOdextrose 5%/potassium chloride 1 GC0.15%eliphos 1 GC MOK-TABS 3 MOkcl 0.075%/d5w/nacl 0.45% 1 GCkcl 0.15%/d5w/lr 1 GC MOkcl 0.15%/d5w/nacl 0.2% 1 GC MOkcl 0.15%/d5w/nacl 0.225% 1 GC MOkcl 0.15%/d5w/nacl 0.9% 1 GCkcl 0.3%/d5w/nacl 0.45% 1 GCkcl 0.3%/d5w/nacl 0.9% 1 GCklor-con 10 1 GC MOklor-con 8 1 GC MOKLOR-CON M15 3 MOklor-con m20 1 GC MOlactated ringers viaflex 1 GC MOmagnesium sulfate inj 50% 1 GCNORMOSOL-R IN D5W 2PHOSLYRA 2 MOpotassium chloride 0.15% /nacl0.45% viaflexpotassium chloride 0.15%d5w/nacl 0.33%potassium chloride 0.15%d5w/nacl 0.45% viaflexpotassium chloride 0.15% nacl0.9%potassium chloride 0.22%d5w/nacl 0.45%potassium chloride0.224%/dextrose 5% viaflex1 GC1 GC1 GC MO1 GC1 GC1 GCDrugNameDrugTierRequirements/Limitspotassium chloride 0.3%/ nacl 1 GC0.9%potassium chloride 0.3%/d5w 1 GCpotassium chloride er cpcr 1 GC MOpotassium chloride er tbcr 10meq, 1 GC MO20meqpotassium chloride inj 0.4meq/ml, 1 GC10meq/100ml, 10meq/50ml,30meq/100mlpotassium chloride inj 2meq/ml 1 GC MOringers injection 1 GCsodium chloride 0.45% viaflex 1 GC MOsodium chloride inj 5% 1 GCsodium chloride inj 2.5meq/ml, 1 GC MO3%MISCELLANEOUS NUTRITIONPRODUCTSAMINOSYN II 2AMINOSYN II28.5%/ELECTROLYTESAMINOSYN-HBC 2AMINOSYN-PF 2AMINOSYN-PF 7% 2CLINIMIX 2.75%/DEXTROSE 25%CLINIMIX 4.25%/DEXTROSE 210%CLINIMIX 4.25%/DEXTROSE 220%CLINIMIX 4.25%/DEXTROSE 225%CLINIMIX 5%/DEXTROSE 15% 2CLINIMIX 5%/DEXTROSE 20% 2CLINIMIX 5%/DEXTROSE 25% 2CLINISOL SF 15% 2 MO40