Choice Plan - Express Scripts

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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
DrugNameDrugTierRequirements/LimitsFREAMINE III INJ 72MEQ/L; 2 MO600MG/100ML; 810MG/100ML;3MEQ/L; 14MG/100ML;1190MG/100ML;240MG/100ML; 590MG/100ML;770MG/100ML; 620MG/100ML;450MG/100ML; 480MG/100ML;10MMOLE/L; 115MG/100ML;950MG/100ML; 500MG/100ML;10MEQ/L; 340MG/100ML;130MG/100ML; 560MG/100MLHEPATAMINE 2HEPATASOL 2INTRALIPID INJ 1.7%; 30% 2intralipid inj 2.25%; 20% 1 GC MOIONOSOL-B/DEXTROSE 5% 2IONOSOL-MB/DEXTROSE 5% 2ISOLYTE-H/DEXTROSE 5% 2ISOLYTE-P/DEXTROSE 5% 2ISOLYTE-S 2ISOLYTE-S/DEXTROSE 5% 2liposyn iii inj 1.2%; 2.5%; 10% 1 GCNEPHRAMINE 2NORMOSOL-R 2PLASMA-LYTE A 2PLASMA-LYTE-148 2PLASMA-LYTE-56/D5W 2PREMASOL INJ 56MEQ/L;320MG/100ML; 730MG/100ML;190MG/100ML; 3MEQ/L;20MG/100ML; 300MG/100ML;220MG/100ML; 290MG/100ML;490MG/100ML; 840MG/100ML;490MG/100ML; 200MG/100ML;290MG/100ML; 410MG/100ML;230MG/100ML; 5MEQ/L;15MG/100ML; 250MG/100ML;120MG/100ML; 140MG/100ML;470MG/100ML2DrugNameDrugTierRequirements/Limitspremasol inj 52meq/l;1 GC1760mg/100ml; 880mg/100ml;34meq/l; 1760mg/100ml;372mg/100ml; 406mg/100ml;526mg/100ml; 492mg/100ml;492mg/100ml; 526mg/100ml;356mg/100ml; 356mg/100ml;390mg/100ml; 34mg/100ml;152mg/100mltravasol 2TROPHAMINE 2VITAMINS / HEMATINICSprenatabs obn 1 GCsodium fluoride tabs 1 GC41
Page 1 and 2: Choice planExpress Scripts Medicare
Page 3 and 4: Alphabetical ListingIf you are not
Page 5 and 6: What do I do before I can talk to m
Page 7: Below is a list of abbreviations th
Page 10 and 11: DrugNameDrugTierRequirements/Limits
Page 50 and 51: 8Index of Drugs8-MOP ..............
Page 52 and 53: enazepril hcl/hydrochlorothiazide .
Page 54 and 55: COLCRYS ...........................
Page 56 and 57: enalapril maleate/hydrochlorothiazi
Page 58 and 59: HHALAVEN ..........................
Page 60 and 61: lamotrigine .......................
Page 62 and 63: montelukast sodium ................
Page 64 and 65: PEG-INTRON ........................
Page 66 and 67: ifampin............................
Page 68 and 69: TOBREX ............................
Page 70: ZIRGAN ............................

Choice Plan - Express Scripts

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