Choice Plan - Express Scripts

Commonly Prescribed TherapeuticDrug CategoriesANTI - INFECTIVESANTIFUNGAL AGENTSDrugNameDrugTierRequirements/Limitsamphotericin b 1 GC PA MOANCOBON 2 MOclotrimazole troc 1 GC MOERAXIS INJ 100MG 2 MOfluconazole 1 GC MOfluconazole in dextrose inj 1 GC56mg/ml; 400mg/200mlflucytosine 1 GC MOGRIS-PEG 3 MOgriseofulvin microsize 1 GC MOgriseofulvin ultramicrosize 1 GC MOitraconazole 1 GC MOketoconazole 1 GC MONOXAFIL 2 MOnystatin susp 1 GC MOnystatin tabs 1 GC MOSPORANOX ORAL SOLN 2 MOterbinafine hcl tabs 1 GC MOVFEND IV 2 MOVFEND SUSR 2 MOvoriconazole 1 GC MOANTIVIRALSabacavir 1 GC QL(180per 90 days)MOacyclovir 1 GC MOacyclovir sodium inj 500mg 1 GC MOamantadine hcl 1 GC MOAPTIVUS CAPS 4 QL(360 per90 days)MOAPTIVUS ORAL SOLN 4 QL(950 per90 days)ATRIPLA 4 QL(90 per90 days)MODrugNameDrugTierRequirements/LimitsBARACLUDE ORAL SOLN 2 QL(1890per 90 days)MOBARACLUDE TABS 2 QL(90 per90 days)MOCIDOFOVIR 4 MOCOMPLERA 4 QL(90 per90 days)MOCRIXIVAN 2 MOdidanosine 1 GC QL(90per 90 days)MOEDURANT 4 QL(90 per90 days)MOEMTRIVA CAPS 2 QL(90 per90 days)MOEMTRIVA ORAL SOLN 2 QL(2210per 90 days)MOEPIVIR HBV 2 MOEPIVIR ORAL SOLN 2 QL(2880per 90 days)MOEPZICOM 4 QL(90 per90 days)MOfamciclovir 1 GC MOfoscarnet sodium 1 GC PA MOFUZEON 4 QL(180 per90 days)MOganciclovir 1 GC MOHEPSERA 4 QL(90 per90 days)MOINCIVEK 4 PA QL(504per 84 days)MOINTELENCE TABS 200MG 4 QL(180 per90 days)MO1