{ "Profile_Information": { "public_name": "Pennsylvania Medicaid Formulary", "state": "PENNSYLVANIA", "formulary_name": "194-620-763_20131030T125047", "formulary_id": 3301, "formulary_version": 49, "formulary_effective_date": "01/09/2018" }, "Drug_Information": [ { "ndc": "66870022416", "ndc_label_name": "12.5CPD-120GFN-5PEH LIQUID", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "08517359036", "ndc_label_name": "1ST TIER UNIFINE PNTIP 6MM 31G", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61059059036", "ndc_label_name": "1ST TIER UNIFINE PNTIP 6MM 31G", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08517353036", "ndc_label_name": "1ST TIER UNIFINE PNTIP 8MM 31G", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08517383036", "ndc_label_name": "1ST TIER UNIFINE PNTIP 8MM 31G", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61059053036", "ndc_label_name": "1ST TIER UNIFINE PNTIP 8MM 31G", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61059083036", "ndc_label_name": "1ST TIER UNIFINE PNTIP 8MM 31G", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08517352936", "ndc_label_name": "1ST TIER UNIFINE PNTP 12MM 29G", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61059052936", "ndc_label_name": "1ST TIER UNIFINE PNTP 12MM 29G", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08517382936", "ndc_label_name": "1ST TIER UNIFINE PNTP 29GX1/2\"", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61059082936", "ndc_label_name": "1ST TIER UNIFINE PNTP 29GX1/2\"", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08517389036", "ndc_label_name": "1ST TIER UNIFINE PNTP 31GX1/4\"", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61059089036", "ndc_label_name": "1ST TIER UNIFINE PNTP 31GX1/4\"", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08517383065", "ndc_label_name": "1ST TIER UNIFINE PNTP 31GX5/16", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61059083065", "ndc_label_name": "1ST TIER UNIFINE PNTP 31GX5/16", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00187065142", "ndc_label_name": "8-MOP 10 MG CAPSULE", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722056224", "ndc_label_name": "ABACAVIR 20 MG/ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378410591", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904652304", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904652306", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722055760", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020401", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020406", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569635100", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505358306", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380071703", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862007360", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084002111", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084002121", "ndc_label_name": "ABACAVIR 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180028607", "ndc_label_name": "ABACAVIR-LAMIVUDINE-ZIDOV TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353084815", "ndc_label_name": "ABILIFY 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353084816", "ndc_label_name": "ABILIFY 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353084845", "ndc_label_name": "ABILIFY 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999059830", "ndc_label_name": "ABILIFY 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959060530", "ndc_label_name": "ABILIFY 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868520200", "ndc_label_name": "ABILIFY 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289025130", "ndc_label_name": "ABILIFY 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148000813", "ndc_label_name": "ABILIFY 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148000835", "ndc_label_name": "ABILIFY 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148000913", "ndc_label_name": "ABILIFY 15 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148000935", "ndc_label_name": "ABILIFY 15 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356056830", "ndc_label_name": "ABILIFY 2 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868628000", "ndc_label_name": "ABILIFY 2 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148000613", "ndc_label_name": "ABILIFY 2 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629338601", "ndc_label_name": "ABILIFY 2 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629338602", "ndc_label_name": "ABILIFY 2 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629338603", "ndc_label_name": "ABILIFY 2 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629338604", "ndc_label_name": "ABILIFY 2 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353084915", "ndc_label_name": "ABILIFY 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353084916", "ndc_label_name": "ABILIFY 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353084945", "ndc_label_name": "ABILIFY 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148001013", "ndc_label_name": "ABILIFY 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148001035", "ndc_label_name": "ABILIFY 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353085015", "ndc_label_name": "ABILIFY 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353085018", "ndc_label_name": "ABILIFY 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353085045", "ndc_label_name": "ABILIFY 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353085099", "ndc_label_name": "ABILIFY 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289056630", "ndc_label_name": "ABILIFY 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148001113", "ndc_label_name": "ABILIFY 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148001135", "ndc_label_name": "ABILIFY 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999081630", "ndc_label_name": "ABILIFY 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959060430", "ndc_label_name": "ABILIFY 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148000713", "ndc_label_name": "ABILIFY 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148000735", "ndc_label_name": "ABILIFY 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629338701", "ndc_label_name": "ABILIFY 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629338702", "ndc_label_name": "ABILIFY 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629338703", "ndc_label_name": "ABILIFY 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629338704", "ndc_label_name": "ABILIFY 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148004580", "ndc_label_name": "ABILIFY MAINTENA ER 300 MG SYR", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148001870", "ndc_label_name": "ABILIFY MAINTENA ER 300 MG VL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148001871", "ndc_label_name": "ABILIFY MAINTENA ER 300 MG VL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148007280", "ndc_label_name": "ABILIFY MAINTENA ER 400 MG SYR", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148007292", "ndc_label_name": "ABILIFY MAINTENA ER 400 MG SYR", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148001970", "ndc_label_name": "ABILIFY MAINTENA ER 400 MG VL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148001971", "ndc_label_name": "ABILIFY MAINTENA ER 400 MG VL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148001991", "ndc_label_name": "ABILIFY MAINTENA ER 400 MG VL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68817013450", "ndc_label_name": "ABRAXANE 100 MG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011531", "ndc_label_name": "ABSORICA 10 MG CAPSULE", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011569", "ndc_label_name": "ABSORICA 10 MG CAPSULE", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011631", "ndc_label_name": "ABSORICA 20 MG CAPSULE", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011669", "ndc_label_name": "ABSORICA 20 MG CAPSULE", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011731", "ndc_label_name": "ABSORICA 30 MG CAPSULE", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011769", "ndc_label_name": "ABSORICA 30 MG CAPSULE", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011831", "ndc_label_name": "ABSORICA 40 MG CAPSULE", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011869", "ndc_label_name": "ABSORICA 40 MG CAPSULE", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42358010032", "ndc_label_name": "ABSTRAL 100 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033104", "ndc_label_name": "ABSTRAL 100 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033132", "ndc_label_name": "ABSTRAL 100 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42358020032", "ndc_label_name": "ABSTRAL 200 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033204", "ndc_label_name": "ABSTRAL 200 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033232", "ndc_label_name": "ABSTRAL 200 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42358030032", "ndc_label_name": "ABSTRAL 300 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033304", "ndc_label_name": "ABSTRAL 300 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033332", "ndc_label_name": "ABSTRAL 300 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42358040032", "ndc_label_name": "ABSTRAL 400 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033404", "ndc_label_name": "ABSTRAL 400 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033432", "ndc_label_name": "ABSTRAL 400 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42358060032", "ndc_label_name": "ABSTRAL 600 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033604", "ndc_label_name": "ABSTRAL 600 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033632", "ndc_label_name": "ABSTRAL 600 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42358080032", "ndc_label_name": "ABSTRAL 800 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033804", "ndc_label_name": "ABSTRAL 800 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57881033832", "ndc_label_name": "ABSTRAL 800 MCG TAB SUBLINGUAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65702040710", "ndc_label_name": "ACCU-CHEK AVIVA PLUS TEST STRP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702040810", "ndc_label_name": "ACCU-CHEK AVIVA PLUS TEST STRP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702043710", "ndc_label_name": "ACCU-CHEK AVIVA PLUS TEST STRP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702043810", "ndc_label_name": "ACCU-CHEK AVIVA PLUS TEST STRP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702059110", "ndc_label_name": "ACCU-CHEK AVIVA PLUS TEST STRP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702010710", "ndc_label_name": "ACCU-CHEK AVIVA SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702028810", "ndc_label_name": "ACCU-CHEK FASTCLIX LANCETS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702068810", "ndc_label_name": "ACCU-CHEK GUIDE L1-L2 CTRL SOL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702071310", "ndc_label_name": "ACCU-CHEK GUIDE L1-L2 CTRL SOL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702061710", "ndc_label_name": "ACCU-CHEK GUIDE MONITOR SYSTEM", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702070204", "ndc_label_name": "ACCU-CHEK GUIDE MONITOR SYSTEM", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702070195", "ndc_label_name": "ACCU-CHEK GUIDE TEST STRIP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702071110", "ndc_label_name": "ACCU-CHEK GUIDE TEST STRIP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50924044601", "ndc_label_name": "ACCU-CHEK MULTICLIX LANCET KIT", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50924045001", "ndc_label_name": "ACCU-CHEK MULTICLIX LANCETS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50924098101", "ndc_label_name": "ACCU-CHEK MULTICLIX LANCETS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "75537045097", "ndc_label_name": "ACCU-CHEK MULTICLIX LANCETS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702048810", "ndc_label_name": "ACCU-CHEK SMARTVIEW CONTRL SOL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702049210", "ndc_label_name": "ACCU-CHEK SMARTVIEW TEST STRIP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702049310", "ndc_label_name": "ACCU-CHEK SMARTVIEW TEST STRIP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702049410", "ndc_label_name": "ACCU-CHEK SMARTVIEW TEST STRIP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702059210", "ndc_label_name": "ACCU-CHEK SMARTVIEW TEST STRIP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702040010", "ndc_label_name": "ACCU-CHEK SOFTCLIX LANCET KIT", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50924097110", "ndc_label_name": "ACCU-CHEK SOFTCLIX LANCETS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702012410", "ndc_label_name": "ACCU-CHEK SOFTCLIX LANCETS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65702015610", "ndc_label_name": "ACCU-CHEK SOFTCLIX LANCETS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "75537000971", "ndc_label_name": "ACCU-CHEK SOFTCLIX LANCETS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00071053023", "ndc_label_name": "ACCUPRIL 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00071053040", "ndc_label_name": "ACCUPRIL 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289055330", "ndc_label_name": "ACCUPRIL 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864085930", "ndc_label_name": "ACCUPRIL 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00071053223", "ndc_label_name": "ACCUPRIL 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00071053240", "ndc_label_name": "ACCUPRIL 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289055430", "ndc_label_name": "ACCUPRIL 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864086930", "ndc_label_name": "ACCUPRIL 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00071053523", "ndc_label_name": "ACCUPRIL 40 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289055530", "ndc_label_name": "ACCUPRIL 40 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864086330", "ndc_label_name": "ACCUPRIL 40 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629124201", "ndc_label_name": "ACCUPRIL 40 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00071052723", "ndc_label_name": "ACCUPRIL 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00071052740", "ndc_label_name": "ACCUPRIL 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289055230", "ndc_label_name": "ACCUPRIL 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00071022223", "ndc_label_name": "ACCURETIC 10-12.5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00071022023", "ndc_label_name": "ACCURETIC 20-12.5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00071022323", "ndc_label_name": "ACCURETIC 20-25 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61894000102", "ndc_label_name": "ACEON 4 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61894000202", "ndc_label_name": "ACEON 8 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713016401", "ndc_label_name": "ACEPHEN 325 MG SUPPOSITORY", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00713016406", "ndc_label_name": "ACEPHEN 325 MG SUPPOSITORY", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00713016412", "ndc_label_name": "ACEPHEN 325 MG SUPPOSITORY", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00713016450", "ndc_label_name": "ACEPHEN 325 MG SUPPOSITORY", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "42195084010", "ndc_label_name": "ACETAMIN-CAFF-DIHYDROCOD 320.5", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121050404", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121050416", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603102058", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603901354", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603901358", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383007916", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569100100", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868037801", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868037802", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432024504", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432024516", "ndc_label_name": "ACETAMINOP-CODEINE 120-12 MG/5", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "11673010526", "ndc_label_name": "ACETAMINOPHEN 160 MG/5 ML SUSP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673013026", "ndc_label_name": "ACETAMINOPHEN 160 MG/5 ML SUSP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673013316", "ndc_label_name": "ACETAMINOPHEN 160 MG/5 ML SUSP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569635700", "ndc_label_name": "ACETAMINOPHEN 160 MG/5 ML SUSP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012301", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012305", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012310", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012324", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012330", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012350", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012357", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012360", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012362", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012365", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012370", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135012390", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135016313", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135016314", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11383013917", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673044478", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917004394", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917006767", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "32363013915", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33358000620", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33358000630", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33358000660", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864000101", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864000102", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864007039", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41163010412", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41163047159", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292056451", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292056452", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43353043390", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "47682014513", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "47682014536", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "47682014548", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "47682014564", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "47682014599", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483034001", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49999013130", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070301", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070310", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070399", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959030200", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959030212", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959030220", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959030224", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959030230", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959030240", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959030260", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959030295", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "53329064230", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569153301", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569153302", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569153303", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569153304", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569510101", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54738054801", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54738054803", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54738054850", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54868054802", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54868054803", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54868054804", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289056301", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289056312", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289056320", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289056324", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289056330", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289056350", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896010101", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896010105", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896010110", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58864000256", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63187052800", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151801", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151802", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151803", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151804", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63739044001", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267000330", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267000340", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267099900", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67544048065", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67544048090", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "69618001001", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "69618001010", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015201", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015202", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015203", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015204", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012976", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012982", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012983", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295013128", "ndc_label_name": "ACETAMINOPHEN 325 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014401", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014405", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014410", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014424", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014450", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014460", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014466", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014470", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135016413", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10267011901", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10267011904", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10267011905", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10267011906", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10267119001", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10267119004", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10267119005", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10267119006", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673048471", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673048478", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673048483", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673060608", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673060613", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673060619", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673060621", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917001168", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917001170", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917004918", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917006769", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917006772", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864000110", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864000111", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43063022450", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43063022460", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292055615", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802048478", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802048490", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070501", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070510", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959033800", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959033810", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959033812", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959033820", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959033824", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959033830", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959033840", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959033850", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959033860", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54257058917", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54257058918", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569002300", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54738004001", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54738004003", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54868383200", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896022101", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896022110", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58864006130", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "60760004824", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68196055361", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015101", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015102", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015103", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015104", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015105", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012970", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012971", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012972", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012977", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012980", "ndc_label_name": "ACETAMINOPHEN 500 MG CAPLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917006512", "ndc_label_name": "ACETAMINOPHEN 500 MG GELCAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917006513", "ndc_label_name": "ACETAMINOPHEN 500 MG GELCAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959041240", "ndc_label_name": "ACETAMINOPHEN 500 MG GELCAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959041250", "ndc_label_name": "ACETAMINOPHEN 500 MG GELCAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015201", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015210", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015213", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015224", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015230", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015250", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015256", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015257", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015260", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015266", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135015270", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673022778", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33358000700", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33358000701", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33358000715", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33358000720", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33358000730", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33358000740", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33358000745", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35356085730", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864000103", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864000104", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864070699", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "47682017513", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "47682017533", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "47682017548", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "47682017564", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483034101", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483034110", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49999009930", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49999009960", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070601", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070610", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070699", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000200", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000210", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000215", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000220", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000224", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000225", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000230", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000240", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000245", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000250", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959000290", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54257059217", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569276400", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569276401", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569276402", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569276403", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569276404", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569276405", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569276407", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54738054001", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54738054003", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289088001", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289088006", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289088012", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289088015", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289088020", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289088024", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "55289088030", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896020005", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896020010", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896020101", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63187029330", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63187029340", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63187029350", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151600", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151601", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151602", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151603", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151604", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151605", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151606", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151607", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151608", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629151609", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267000520", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267000530", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267000545", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267000550", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267099800", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67544061265", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67544061290", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "69618001101", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "69618001110", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015001", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015002", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70030062060", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012969", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012973", "ndc_label_name": "ACETAMINOPHEN 500 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68084077725", "ndc_label_name": "ACETAMINOPHEN ER 650 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68084077795", "ndc_label_name": "ACETAMINOPHEN ER 650 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00093005001", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406048301", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603233721", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13107005801", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959020815", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959020830", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569031100", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569031102", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289044915", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629294501", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267022130", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000160", "ndc_label_name": "ACETAMINOPHEN-COD #2 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093015001", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093015010", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406048401", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406048403", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406048410", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406048420", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406048423", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406048450", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406048462", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702010", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702012", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702015", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702020", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702030", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702081", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702085", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702610", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702612", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702615", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702620", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702630", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702681", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440702685", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603233802", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603233804", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603233816", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603233820", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603233821", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603233822", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603233832", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13107005901", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13107005999", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358000101", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358000115", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358000120", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358000130", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358000160", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001403", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001404", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001406", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001412", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055406", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055410", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055412", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055415", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055418", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055420", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055424", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055425", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055428", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055430", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055460", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055490", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055498", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353001045", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353001050", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353001060", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353001070", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353001075", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353001090", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006000", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006006", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006010", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006012", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006015", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006020", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006024", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006030", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006060", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006090", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079016101", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079016120", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079016121", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079016199", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000300", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000302", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000304", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000306", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000310", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000312", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000315", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000316", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000320", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000324", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000325", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000328", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000330", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000340", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000350", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000360", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000390", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569002500", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569002501", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569002502", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569002503", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569002504", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569002506", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569002507", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569002509", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569252301", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569252304", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569252307", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007201", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007202", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007204", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007207", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007208", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007209", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000506", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000510", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000512", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000515", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000518", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000520", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000524", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000525", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000530", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000560", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000590", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289000598", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700021310", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700021312", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700021315", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700021320", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700021330", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700021360", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864000415", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864000420", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864000430", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760002215", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760002230", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919002330", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919002360", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919002371", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919002390", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187081520", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187081530", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149400", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149401", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149402", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149403", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149404", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149405", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149406", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149407", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149408", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149409", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739000410", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162003310", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162003311", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000106", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000110", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000112", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000115", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000120", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000124", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000130", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000140", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000160", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000190", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000215", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000220", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000230", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000240", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000245", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000250", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000253", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000255", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000260", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000270", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000275", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000280", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000285", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000290", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000293", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544034580", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088220", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088230", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088240", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088245", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088250", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088253", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088255", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088260", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088270", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088275", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088280", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544088290", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084037201", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084037211", "ndc_label_name": "ACETAMINOPHEN-COD #3 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093035001", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093035005", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093035010", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406048501", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406048505", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603233921", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603233928", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13107006001", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13107006005", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13107006099", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358000260", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999002630", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999002660", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959044600", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959044624", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959044630", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959044660", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030201", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030202", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030208", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868086003", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289091620", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289091630", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289091690", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629303101", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629303102", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629303103", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629303104", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629303105", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000220", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000230", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000240", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000260", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000360", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000370", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544047453", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544047460", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544047470", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544047480", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544047490", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084037301", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084037311", "ndc_label_name": "ACETAMINOPHEN-COD #4 TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472088282", "ndc_label_name": "ACETASOL HC EAR DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959031901", "ndc_label_name": "ACETASOL HC EAR DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267099610", "ndc_label_name": "ACETASOL HC EAR DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155028701", "ndc_label_name": "ACETAZOLAMIDE 125 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291008901", "ndc_label_name": "ACETAZOLAMIDE 125 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672402201", "ndc_label_name": "ACETAZOLAMIDE 125 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569438701", "ndc_label_name": "ACETAZOLAMIDE 125 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289072006", "ndc_label_name": "ACETAZOLAMIDE 125 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289072012", "ndc_label_name": "ACETAZOLAMIDE 125 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429003301", "ndc_label_name": "ACETAZOLAMIDE 125 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380083306", "ndc_label_name": "ACETAZOLAMIDE 125 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527105001", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10135056701", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155028801", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291009001", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010310", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010390", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672402301", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569169700", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868119500", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868119502", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868119503", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868119504", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289022124", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429003401", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380083406", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084054101", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084054111", "ndc_label_name": "ACETAZOLAMIDE 250 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555051302", "ndc_label_name": "ACETAZOLAMIDE ER 500 MG CAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155012001", "ndc_label_name": "ACETAZOLAMIDE ER 500 MG CAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29033003001", "ndc_label_name": "ACETAZOLAMIDE ER 500 MG CAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742023301", "ndc_label_name": "ACETAZOLAMIDE ER 500 MG CAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084040111", "ndc_label_name": "ACETAZOLAMIDE ER 500 MG CAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084040121", "ndc_label_name": "ACETAZOLAMIDE ER 500 MG CAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382026101", "ndc_label_name": "ACETAZOLAMIDE ER 500 MG CAP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603703841", "ndc_label_name": "ACETIC ACID 2% EAR SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383088915", "ndc_label_name": "ACETIC ACID 2% EAR SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569231100", "ndc_label_name": "ACETIC ACID 2% EAR SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432074115", "ndc_label_name": "ACETIC ACID 2% EAR SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208061577", "ndc_label_name": "ACETIC ACID-ALUMINUM DROPS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409330703", "ndc_label_name": "ACETYLCYSTEINE 10% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517750425", "ndc_label_name": "ACETYLCYSTEINE 10% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517751003", "ndc_label_name": "ACETYLCYSTEINE 10% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069130", "ndc_label_name": "ACETYLCYSTEINE 10% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069310", "ndc_label_name": "ACETYLCYSTEINE 10% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069504", "ndc_label_name": "ACETYLCYSTEINE 10% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409330803", "ndc_label_name": "ACETYLCYSTEINE 20% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517760425", "ndc_label_name": "ACETYLCYSTEINE 20% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517761003", "ndc_label_name": "ACETYLCYSTEINE 20% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517763003", "ndc_label_name": "ACETYLCYSTEINE 20% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868567000", "ndc_label_name": "ACETYLCYSTEINE 20% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069030", "ndc_label_name": "ACETYLCYSTEINE 20% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069210", "ndc_label_name": "ACETYLCYSTEINE 20% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069404", "ndc_label_name": "ACETYLCYSTEINE 20% VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358000830", "ndc_label_name": "ACIPHEX DR 20 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358000860", "ndc_label_name": "ACIPHEX DR 20 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569498000", "ndc_label_name": "ACIPHEX DR 20 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868418500", "ndc_label_name": "ACIPHEX DR 20 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868418501", "ndc_label_name": "ACIPHEX DR 20 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868418502", "ndc_label_name": "ACIPHEX DR 20 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62856024330", "ndc_label_name": "ACIPHEX DR 20 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629273302", "ndc_label_name": "ACIPHEX DR 20 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629273303", "ndc_label_name": "ACIPHEX DR 20 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000445", "ndc_label_name": "ACIPHEX DR 20 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242013801", "ndc_label_name": "ACTEMRA 162 MG/0.9 ML SYRINGE", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242013601", "ndc_label_name": "ACTEMRA 200 MG/10 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242013701", "ndc_label_name": "ACTEMRA 400 MG/20 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242013501", "ndc_label_name": "ACTEMRA 80 MG/4 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55566030201", "ndc_label_name": "ACTHREL 100 MCG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544093001", "ndc_label_name": "ACTIGALL 300 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42238011101", "ndc_label_name": "ACTIMMUNE 100 MCG/0.5 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42238011112", "ndc_label_name": "ACTIMMUNE 100 MCG/0.5 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356046030", "ndc_label_name": "ACTIQ 1,200 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459051201", "ndc_label_name": "ACTIQ 1,200 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459051230", "ndc_label_name": "ACTIQ 1,200 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356046130", "ndc_label_name": "ACTIQ 1,600 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459051601", "ndc_label_name": "ACTIQ 1,600 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459051630", "ndc_label_name": "ACTIQ 1,600 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356045630", "ndc_label_name": "ACTIQ 200 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459050201", "ndc_label_name": "ACTIQ 200 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459050230", "ndc_label_name": "ACTIQ 200 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459050401", "ndc_label_name": "ACTIQ 400 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459050430", "ndc_label_name": "ACTIQ 400 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459050601", "ndc_label_name": "ACTIQ 600 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459050630", "ndc_label_name": "ACTIQ 600 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459050801", "ndc_label_name": "ACTIQ 800 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459050830", "ndc_label_name": "ACTIQ 800 MCG LOZENGE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242008525", "ndc_label_name": "ACTIVASE 100 MG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242008527", "ndc_label_name": "ACTIVASE 100 MG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242004406", "ndc_label_name": "ACTIVASE 50 MG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242004413", "ndc_label_name": "ACTIVASE 50 MG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023218105", "ndc_label_name": "ACULAR 0.5% EYE DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959011405", "ndc_label_name": "ACULAR 0.5% EYE DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569408300", "ndc_label_name": "ACULAR 0.5% EYE DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023927705", "ndc_label_name": "ACULAR LS 0.4% OPHTH SOL", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894001", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894005", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603001", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603005", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603030", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603060", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603081", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703005", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703025", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703030", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703050", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703060", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904578961", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544014630", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155014601", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358000925", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010701", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010750", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063070135", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063070150", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006011", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006015", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051725", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051730", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051735", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051750", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569448200", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569448201", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569448204", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569448206", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399600", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399602", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399603", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399605", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027305", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027310", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027325", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027330", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027335", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027350", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864087635", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429001201", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429001205", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505004206", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760065225", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011101", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011105", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187018290", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304065201", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000625", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000640", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000650", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010701", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010711", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69076014601", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834012401", "ndc_label_name": "ACYCLOVIR 200 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472008216", "ndc_label_name": "ACYCLOVIR 200 MG/5 ML SUSP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "40085084296", "ndc_label_name": "ACYCLOVIR 200 MG/5 ML SUSP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383081016", "ndc_label_name": "ACYCLOVIR 200 MG/5 ML SUSP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868568700", "ndc_label_name": "ACYCLOVIR 200 MG/5 ML SUSP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894301", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894305", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378025301", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440103130", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603101", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603105", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603125", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603130", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603181", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703125", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904579061", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544015130", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544015160", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094214", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094260", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155022701", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155022705", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722077701", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722077705", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001015", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001028", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001030", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001060", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356090315", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356090330", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356090335", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356090340", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010850", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010890", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063000101", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034004", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034015", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034030", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034060", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999008630", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006111", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006115", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054401", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054410", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054412", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054415", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054421", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054425", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054430", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054440", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054450", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054460", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476501", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476502", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476503", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476504", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476505", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476506", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476509", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399700", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399701", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399702", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399703", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399704", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399705", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046201", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046205", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046212", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046215", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046221", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046225", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046230", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046235", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046240", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046260", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864060201", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864060230", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429030901", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429030905", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505530601", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505530608", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011201", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011205", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919037030", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187025315", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187025330", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304050401", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167701", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167702", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167703", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167704", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167705", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167706", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167707", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739068210", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000715", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000721", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000725", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000730", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253010110", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253010111", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010801", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010811", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382079101", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382079105", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834012201", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834012205", "ndc_label_name": "ACYCLOVIR 400 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894701", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894705", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378030201", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603301", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603305", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603310", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603320", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603381", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703310", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703320", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703350", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544020435", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155022801", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155022805", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722077801", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722077805", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001125", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001130", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001135", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010950", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010990", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063058910", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063058930", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063058935", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063058950", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353093318", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999023100", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999023115", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999023130", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999023135", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006211", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006215", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959067830", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959067840", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959067850", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569472400", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569472402", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399800", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399801", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399803", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399804", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399805", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399806", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868399808", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062910", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062920", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062930", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062935", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062940", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062950", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864019125", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864019135", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429031001", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505530701", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505530705", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011301", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011305", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919000335", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304050501", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167801", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167802", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167803", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167804", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167805", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267039930", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267039935", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253010210", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253010250", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010901", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010911", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382079201", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382079205", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834012301", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834012305", "ndc_label_name": "ACYCLOVIR 800 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49281040015", "ndc_label_name": "ADACEL TDAP SYRINGE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49281040020", "ndc_label_name": "ADACEL TDAP SYRINGE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49281040088", "ndc_label_name": "ADACEL TDAP SYRINGE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49281040089", "ndc_label_name": "ADACEL TDAP SYRINGE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49281040010", "ndc_label_name": "ADACEL TDAP VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49281040058", "ndc_label_name": "ADACEL TDAP VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57665000101", "ndc_label_name": "ADAGEN 250 UNITS/ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419070105", "ndc_label_name": "ADALAT CC 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419070110", "ndc_label_name": "ADALAT CC 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52427049401", "ndc_label_name": "ADALAT CC 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864066914", "ndc_label_name": "ADALAT CC 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419070205", "ndc_label_name": "ADALAT CC 60 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419070210", "ndc_label_name": "ADALAT CC 60 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52427049501", "ndc_label_name": "ADALAT CC 60 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289054330", "ndc_label_name": "ADALAT CC 60 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419070305", "ndc_label_name": "ADALAT CC 90 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52427049601", "ndc_label_name": "ADALAT CC 90 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289054530", "ndc_label_name": "ADALAT CC 90 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544018560", "ndc_label_name": "ADALAT CC 90 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544018581", "ndc_label_name": "ADALAT CC 90 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544018582", "ndc_label_name": "ADALAT CC 90 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51144005001", "ndc_label_name": "ADCETRIS 50 MG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353007012", "ndc_label_name": "ADCIRCA 20 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66302046760", "ndc_label_name": "ADCIRCA 20 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555076402", "ndc_label_name": "ADDERALL 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57844011001", "ndc_label_name": "ADDERALL 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555076502", "ndc_label_name": "ADDERALL 12.5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57844011201", "ndc_label_name": "ADDERALL 12.5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57844011501", "ndc_label_name": "ADDERALL 15 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555076702", "ndc_label_name": "ADDERALL 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57844012001", "ndc_label_name": "ADDERALL 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629376901", "ndc_label_name": "ADDERALL 20 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555076802", "ndc_label_name": "ADDERALL 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57844013001", "ndc_label_name": "ADDERALL 30 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555076202", "ndc_label_name": "ADDERALL 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356063130", "ndc_label_name": "ADDERALL 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57844010501", "ndc_label_name": "ADDERALL 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555076302", "ndc_label_name": "ADDERALL 7.5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57844011701", "ndc_label_name": "ADDERALL 7.5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54092038301", "ndc_label_name": "ADDERALL XR 10 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868476001", "ndc_label_name": "ADDERALL XR 10 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868476002", "ndc_label_name": "ADDERALL XR 10 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868476003", "ndc_label_name": "ADDERALL XR 10 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54092038501", "ndc_label_name": "ADDERALL XR 15 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868514000", "ndc_label_name": "ADDERALL XR 15 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868514001", "ndc_label_name": "ADDERALL XR 15 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54092038701", "ndc_label_name": "ADDERALL XR 20 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868464000", "ndc_label_name": "ADDERALL XR 20 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868464001", "ndc_label_name": "ADDERALL XR 20 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868464002", "ndc_label_name": "ADDERALL XR 20 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54092038901", "ndc_label_name": "ADDERALL XR 25 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868536800", "ndc_label_name": "ADDERALL XR 25 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868536801", "ndc_label_name": "ADDERALL XR 25 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54092039101", "ndc_label_name": "ADDERALL XR 30 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868514200", "ndc_label_name": "ADDERALL XR 30 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868514201", "ndc_label_name": "ADDERALL XR 30 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54092038101", "ndc_label_name": "ADDERALL XR 5 MG CAPSULE", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42794000308", "ndc_label_name": "ADEFOVIR DIPIVOXIL 10 MG TAB", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42023010301", "ndc_label_name": "ADRENALIN 1 MG/ML NASAL SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703301811", "ndc_label_name": "ADRUCIL 2,500 MG/50 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703301812", "ndc_label_name": "ADRUCIL 2,500 MG/50 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703301911", "ndc_label_name": "ADRUCIL 5 GRAM/100 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703301912", "ndc_label_name": "ADRUCIL 5 GRAM/100 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703301511", "ndc_label_name": "ADRUCIL 500 MG/10 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703301513", "ndc_label_name": "ADRUCIL 500 MG/10 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944292402", "ndc_label_name": "ADVATE 1,201-1,800 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944305402", "ndc_label_name": "ADVATE 1,201-1,800 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944305403", "ndc_label_name": "ADVATE 1,201-1,800 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944305404", "ndc_label_name": "ADVATE 1,201-1,800 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944296310", "ndc_label_name": "ADVATE 1,201-1,800 UNITS VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944294810", "ndc_label_name": "ADVATE 3,601-4,800 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944304710", "ndc_label_name": "ADVATE 3,601-4,800 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078056751", "ndc_label_name": "AFINITOR 10 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078056761", "ndc_label_name": "AFINITOR 10 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078059451", "ndc_label_name": "AFINITOR 2.5 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078059461", "ndc_label_name": "AFINITOR 2.5 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078056651", "ndc_label_name": "AFINITOR 5 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078056661", "ndc_label_name": "AFINITOR 5 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062051", "ndc_label_name": "AFINITOR 7.5 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062061", "ndc_label_name": "AFINITOR 7.5 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062651", "ndc_label_name": "AFINITOR DISPERZ 2 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062661", "ndc_label_name": "AFINITOR DISPERZ 2 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062751", "ndc_label_name": "AFINITOR DISPERZ 3 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062761", "ndc_label_name": "AFINITOR DISPERZ 3 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062851", "ndc_label_name": "AFINITOR DISPERZ 5 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062861", "ndc_label_name": "AFINITOR DISPERZ 5 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33332001701", "ndc_label_name": "AFLURIA 2017-2018 SYRINGE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33332001702", "ndc_label_name": "AFLURIA 2017-2018 SYRINGE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33332011710", "ndc_label_name": "AFLURIA 2017-2018 VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33332011711", "ndc_label_name": "AFLURIA 2017-2018 VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33332031701", "ndc_label_name": "AFLURIA QUAD 2017-2018 SYRINGE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33332031702", "ndc_label_name": "AFLURIA QUAD 2017-2018 SYRINGE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33332041710", "ndc_label_name": "AFLURIA QUAD 2017-2018 VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33332041711", "ndc_label_name": "AFLURIA QUAD 2017-2018 VIAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00573262065", "ndc_label_name": "ALAVERT 10 MG ODT", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00573262119", "ndc_label_name": "ALAVERT 10 MG ODT", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00573262165", "ndc_label_name": "ALAVERT 10 MG ODT", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "23490935803", "ndc_label_name": "ALAVERT 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00573266012", "ndc_label_name": "ALAVERT D-12 ALLERGY-SINUS TAB", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00573266024", "ndc_label_name": "ALAVERT D-12 ALLERGY-SINUS TAB", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "24208060110", "ndc_label_name": "ALAWAY 0.025% EYE DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54569633800", "ndc_label_name": "ALAWAY 0.025% EYE DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "52054055022", "ndc_label_name": "ALBENZA 200 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52054055028", "ndc_label_name": "ALBENZA 200 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "08620219121", "ndc_label_name": "ALBUSTIX REAGENT STRIPS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49999034425", "ndc_label_name": "ALBUTEROL 0.083% INHAL SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70004002086", "ndc_label_name": "ALBUTEROL 15 MG/3 ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70004002087", "ndc_label_name": "ALBUTEROL 20 MG/4 ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208034720", "ndc_label_name": "ALBUTEROL 5 MG/ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383074120", "ndc_label_name": "ALBUTEROL 5 MG/ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959074120", "ndc_label_name": "ALBUTEROL 5 MG/ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569390000", "ndc_label_name": "ALBUTEROL 5 MG/ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868340700", "ndc_label_name": "ALBUTEROL 5 MG/ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827031", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827052", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827055", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827062", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827064", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827091", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827093", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487950101", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487950102", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487950103", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487950125", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487950160", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591379730", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591379760", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591379783", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781715529", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781715564", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781715586", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569389900", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868247200", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868247201", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76204020001", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76204020025", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76204020030", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76204020060", "ndc_label_name": "ALBUTEROL SUL 2.5 MG/3 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093066116", "ndc_label_name": "ALBUTEROL SULF 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472082516", "ndc_label_name": "ALBUTEROL SULF 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603100858", "ndc_label_name": "ALBUTEROL SULF 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383074016", "ndc_label_name": "ALBUTEROL SULF 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959015303", "ndc_label_name": "ALBUTEROL SULF 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959015306", "ndc_label_name": "ALBUTEROL SULF 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959015309", "ndc_label_name": "ALBUTEROL SULF 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868288700", "ndc_label_name": "ALBUTEROL SULF 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629182801", "ndc_label_name": "ALBUTEROL SULF 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66689010016", "ndc_label_name": "ALBUTEROL SULF 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378025501", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378025505", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079065701", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079065720", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489017601", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489017605", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569340900", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868107303", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289036320", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289036324", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289036330", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629263801", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629263802", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001030", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084094925", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084094995", "ndc_label_name": "ALBUTEROL SULFATE 2 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378057201", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378057205", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079065801", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079065820", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959090620", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489017701", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489017705", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569287401", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289004530", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629273601", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084095225", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084095295", "ndc_label_name": "ALBUTEROL SULFATE 4 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00113200078", "ndc_label_name": "ALCOHOL 70% SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "08222440006", "ndc_label_name": "ALCOHOL 70% SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "08222440013", "ndc_label_name": "ALCOHOL 70% SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917012807", "ndc_label_name": "ALCOHOL 70% SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917014455", "ndc_label_name": "ALCOHOL 70% SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57515044000", "ndc_label_name": "ALCOHOL 70% SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57515044001", "ndc_label_name": "ALCOHOL 70% SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000011201", "ndc_label_name": "ALCOHOL 70% SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012768", "ndc_label_name": "ALCOHOL 70% SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "46122004378", "ndc_label_name": "ALCOHOL SWAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11673060010", "ndc_label_name": "ALCOHOL SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917012805", "ndc_label_name": "ALCOHOL SWABS", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00025101131", "ndc_label_name": "ALDACTAZIDE 25-25 TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00025103131", "ndc_label_name": "ALDACTONE 100 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00025100131", "ndc_label_name": "ALDACTONE 25 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544070430", "ndc_label_name": "ALDACTONE 25 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544070445", "ndc_label_name": "ALDACTONE 25 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00025104131", "ndc_label_name": "ALDACTONE 50 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "99207026012", "ndc_label_name": "ALDARA 5% CREAM", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58468007001", "ndc_label_name": "ALDURAZYME 2.9 MG/5 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093514101", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093514156", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115167801", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115167808", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378356701", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714063101", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714063102", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41616063683", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41616063688", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079094101", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079094105", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868586200", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862032730", "ndc_label_name": "ALENDRONATE SODIUM 10 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093517229", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093517244", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115167926", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115167930", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115167934", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378356899", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16252059902", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16252059944", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714063201", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714063202", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41616063768", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335063760", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335063768", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868586000", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59746024202", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429005572", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429005574", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862032804", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097022316", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097022376", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543013004", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543013012", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76439013004", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76439013012", "ndc_label_name": "ALENDRONATE SODIUM 35 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093514256", "ndc_label_name": "ALENDRONATE SODIUM 40 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115168008", "ndc_label_name": "ALENDRONATE SODIUM 40 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093514001", "ndc_label_name": "ALENDRONATE SODIUM 5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093514056", "ndc_label_name": "ALENDRONATE SODIUM 5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115167601", "ndc_label_name": "ALENDRONATE SODIUM 5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115167608", "ndc_label_name": "ALENDRONATE SODIUM 5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378356601", "ndc_label_name": "ALENDRONATE SODIUM 5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41616063583", "ndc_label_name": "ALENDRONATE SODIUM 5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41616063588", "ndc_label_name": "ALENDRONATE SODIUM 5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093517129", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093517144", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115168126", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115168130", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115168134", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378356999", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16252060102", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16252060144", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714063301", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714063302", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41616063868", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335063860", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335063868", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079094201", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079094205", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569605001", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868586100", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868586101", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59746024402", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429005672", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429005674", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505259604", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862032904", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097022416", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097022476", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543013104", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543013112", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543013120", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76439013104", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76439013112", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76439013120", "ndc_label_name": "ALENDRONATE SODIUM 70 MG TAB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54746000101", "ndc_label_name": "ALFERON N 5 MILLION UNITS VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378500577", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440500001", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440500005", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440500030", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440500060", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440500081", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440500090", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13668002101", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13668002105", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13668002130", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13668002164", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13668002171", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300015501", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300015519", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722030201", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722030205", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291011001", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291011010", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353074630", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353074660", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353094516", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353094530", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353094560", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335095618", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335095681", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335095688", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868632900", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237011490", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429034701", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505285001", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862024901", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097084407", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097084412", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76282030201", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76282030205", "ndc_label_name": "ALFUZOSIN HCL ER 10 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00002764001", "ndc_label_name": "ALIMTA 100 MG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00002762301", "ndc_label_name": "ALIMTA 500 MG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52609000105", "ndc_label_name": "ALKERAN 2 MG TABLET", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52609300100", "ndc_label_name": "ALKERAN 50 MG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52609300200", "ndc_label_name": "ALKERAN 50 MG VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41167041222", "ndc_label_name": "ALLEGRA ALLERGY 180 MG GELCAP", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167412202", "ndc_label_name": "ALLEGRA ALLERGY 180 MG GELCAP", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167041200", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167041206", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167041214", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167041238", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167041251", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167041274", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167041290", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167412000", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167412002", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167412003", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167412004", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167412005", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167412006", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167412104", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569624200", "ndc_label_name": "ALLEGRA ALLERGY 180 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536102547", "ndc_label_name": "ALLER-CHLOR 2 MG/5 ML SYRUP", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00378013701", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378013710", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591554301", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591554310", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211502", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211504", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211521", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211532", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211593", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904657161", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004101", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004104", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004106", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004107", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004110", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004112", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729013401", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729013416", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001200", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356085630", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356085660", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356085690", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063007920", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063007930", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006311", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006315", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742013501", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742013510", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020501", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020517", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020519", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020520", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959047300", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959047330", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489015601", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489015605", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489015610", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569023303", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007500", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007503", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007504", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007505", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111072901", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111072910", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018001", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018010", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018018", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018090", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760011430", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62584098801", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62584098811", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304053901", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304053910", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167501", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167502", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167503", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167504", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739041010", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073660", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073680", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544098830", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544098860", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544098880", "ndc_label_name": "ALLOPURINOL 100 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378018101", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378018105", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591554401", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591554405", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603211602", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603211621", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603211628", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603211632", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904657261", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714004201", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714004204", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714004205", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714004207", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714004210", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714004211", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729013501", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729013516", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001360", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353008860", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018660", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268006411", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268006415", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436302803", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50742013601", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50742013605", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079020601", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079020617", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079020619", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079020620", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959031100", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53489015701", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53489015705", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53489015710", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569023500", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569023501", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569023503", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868007602", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868007603", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868007606", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868007607", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868007608", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111073001", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111073005", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111073010", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289001001", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289001003", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289001030", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289001090", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700003530", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700003590", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429018101", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429018105", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429018190", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919047130", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62584071301", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62584071311", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304054001", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304054005", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739079610", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267022430", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267022460", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267022490", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544031360", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544033030", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544033060", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544037130", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544037160", "ndc_label_name": "ALLOPURINOL 300 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802010365", "ndc_label_name": "ALOGLIPTIN 12.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802015065", "ndc_label_name": "ALOGLIPTIN 25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802008765", "ndc_label_name": "ALOGLIPTIN 6.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802021172", "ndc_label_name": "ALOGLIPTIN-METFORMIN 12.5-1000", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802016972", "ndc_label_name": "ALOGLIPTIN-METFORMIN 12.5-500", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802023865", "ndc_label_name": "ALOGLIPTIN-PIOGLIT 12.5-15 MG", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802026065", "ndc_label_name": "ALOGLIPTIN-PIOGLIT 12.5-30 MG", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802030465", "ndc_label_name": "ALOGLIPTIN-PIOGLIT 12.5-45 MG", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802035165", "ndc_label_name": "ALOGLIPTIN-PIOGLIT 25-15 MG TB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802040265", "ndc_label_name": "ALOGLIPTIN-PIOGLIT 25-30 MG TB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802049965", "ndc_label_name": "ALOGLIPTIN-PIOGLIT 25-45 MG TB", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62856079701", "ndc_label_name": "ALOXI 0.25 MG/5 ML VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023917705", "ndc_label_name": "ALPHAGAN P 0.15% EYE DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023917710", "ndc_label_name": "ALPHAGAN P 0.15% EYE DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023917715", "ndc_label_name": "ALPHAGAN P 0.15% EYE DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868469000", "ndc_label_name": "ALPHAGAN P 0.15% EYE DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868469002", "ndc_label_name": "ALPHAGAN P 0.15% EYE DROPS", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460302", "ndc_label_name": "ALPHANATE 1,000-400 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460402", "ndc_label_name": "ALPHANATE 1,500-600 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460902", "ndc_label_name": "ALPHANATE 2,000-800 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516461002", "ndc_label_name": "ALPHANATE 2,000-800 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460101", "ndc_label_name": "ALPHANATE 250-100 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460201", "ndc_label_name": "ALPHANATE 500-200 UNIT VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360202", "ndc_label_name": "ALPHANINE SD 1,000 UNITS VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360502", "ndc_label_name": "ALPHANINE SD 1,000 UNITS VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360302", "ndc_label_name": "ALPHANINE SD 1,500 UNITS VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360602", "ndc_label_name": "ALPHANINE SD 1,500 UNITS VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360102", "ndc_label_name": "ALPHANINE SD 500 UNITS VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360402", "ndc_label_name": "ALPHANINE SD 500 UNITS VIAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00228202710", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202750", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202796", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378400105", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603212721", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603212728", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603212732", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781106101", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781106105", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781106110", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904585861", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001430", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001460", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063008806", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037005", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037020", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037030", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037060", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037090", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037098", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035715", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035730", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035753", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035760", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035770", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070515", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070530", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070553", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070560", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070570", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060313", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060318", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060388", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003930", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003960", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003990", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463401", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463402", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079078801", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079078820", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032100", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032102", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032110", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032114", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032120", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032130", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032160", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032190", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375500", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375501", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375502", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375504", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375505", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868292900", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868292901", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868292902", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868292903", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868292905", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868292906", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868292907", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868292908", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096205", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096220", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096230", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096260", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096290", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096298", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762371901", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762371903", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762371904", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919044730", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187091630", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295501", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295502", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295503", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295504", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295505", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295506", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295507", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739064410", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063001", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063005", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063010", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267021930", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267021960", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267021990", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090009", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090010", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090011", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090050", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000515", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000530", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000545", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000553", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000560", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000570", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000580", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012415", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012430", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012445", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012453", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012460", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012470", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041415", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041430", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041445", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041453", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041460", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041470", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073415", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073430", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073445", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073453", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073460", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073470", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073480", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084064701", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084064711", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011020", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011030", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011032", "ndc_label_name": "ALPRAZOLAM 0.25 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202910", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202950", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202996", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378400301", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378400305", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603212821", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603212828", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603212832", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107701", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107705", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107710", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904585961", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001520", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001530", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001540", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001560", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001590", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063006106", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036706", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036715", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036730", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036760", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036790", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036798", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035820", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035830", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035845", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035853", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035860", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035870", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035875", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035880", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035892", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055515", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055520", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055530", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055545", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055553", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055555", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055560", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055570", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055575", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055580", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055590", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055592", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060413", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060418", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060488", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003230", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003260", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003290", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463501", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463502", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079078901", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079078920", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045700", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045702", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045715", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045720", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045728", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045730", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045742", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045745", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045760", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045790", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375600", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375601", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375602", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375603", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375604", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868293000", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868293001", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868293002", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868293003", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868293004", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868293005", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868293007", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868293009", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094506", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094515", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094530", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094560", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094590", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094598", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031330", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031360", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031390", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372001", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372003", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372004", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050360", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050390", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919000530", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919000560", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919000590", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154101", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154102", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154103", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154104", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154105", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154106", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154107", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739066910", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063101", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063105", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063110", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001330", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001360", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001390", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090110", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090111", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090150", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000615", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000620", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000630", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000645", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000653", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000660", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000670", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000675", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000680", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041515", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041520", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041530", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041545", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041553", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041560", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041570", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041575", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041580", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041915", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041920", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041930", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041945", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041953", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041960", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041970", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041975", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041980", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062915", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062920", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062930", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062945", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062953", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062955", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062960", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062970", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062975", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062980", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062990", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062992", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071201509", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084067201", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084067211", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011120", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011130", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011132", "ndc_label_name": "ALPRAZOLAM 0.5 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228203110", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228203150", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228203196", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378400505", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603212921", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603212928", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603212932", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107901", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107905", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107910", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904586061", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001600", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001610", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001620", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001630", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001640", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001660", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356074410", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356074430", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356074460", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356074490", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356075260", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036406", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036430", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036440", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036460", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036490", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036498", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055606", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055630", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055640", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055660", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055690", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055698", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063060930", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063060940", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063060960", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063060990", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035930", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035945", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035953", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035960", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035970", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035975", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035980", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035990", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057215", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057230", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057253", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057260", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057270", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057275", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057280", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057290", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060513", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060518", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060588", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463601", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463602", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463603", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079079001", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079079020", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052400", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052402", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052406", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052410", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052414", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052428", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052430", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052460", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052490", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569461900", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569461901", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569461902", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569461903", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569461906", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868300501", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868300502", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868300503", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868300504", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868300507", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868300508", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092006", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092030", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092040", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092060", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092090", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092098", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031230", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031260", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031290", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372101", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372103", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372104", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050412", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050418", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050430", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050460", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050490", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187044330", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294200", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294201", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294202", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294203", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294204", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294205", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294206", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294207", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294208", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294209", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739067410", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063201", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063205", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063210", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001430", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001460", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001490", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001491", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090210", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090211", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090250", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000715", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000730", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000745", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000753", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000755", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000760", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000770", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000775", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000780", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000790", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029015", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029030", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029045", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029053", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029055", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029060", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029070", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029075", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029080", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029090", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034715", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034730", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034745", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034753", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034755", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034760", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034770", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034775", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034780", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034790", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042015", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042030", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042045", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042053", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042055", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042060", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042070", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042075", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042080", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042090", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011220", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011230", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011232", "ndc_label_name": "ALPRAZOLAM 1 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228203910", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228203950", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378400701", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603213021", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603213028", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781108901", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781108905", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001740", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001760", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001790", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060688", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999025390", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463302", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463303", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086400", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086410", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086430", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086440", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086460", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086490", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569490000", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569490001", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569490002", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868466301", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868466302", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868466304", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868466305", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868466306", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868466307", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289052301", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289052330", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289052340", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289052360", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289052390", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372201", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372203", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050518", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050560", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687015311", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687015321", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330801", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330802", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330803", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330804", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063301", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063305", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267056491", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090310", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090350", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011320", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011330", "ndc_label_name": "ALPRAZOLAM 2 MG TABLET", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64406092201", "ndc_label_name": "ALPROLIX 1,000 UNIT NOMINAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406093301", "ndc_label_name": "ALPROLIX 2,000 UNIT NOMINAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406094401", "ndc_label_name": "ALPROLIX 3,000 UNIT NOMINAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406091101", "ndc_label_name": "ALPROLIX 500 UNIT NOMINAL", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00536009185", "ndc_label_name": "ALUMINUM HYDROXIDE GEL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "17856009103", "ndc_label_name": "ALUMINUM HYDROXIDE GEL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00591493001", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591493005", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781204801", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781204805", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832101550", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832201200", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832201250", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904663061", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10888500602", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10888500603", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155036201", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155036205", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291012550", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291012590", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42543049301", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42543049305", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353085318", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353094705", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999032430", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006911", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006915", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079024701", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079024720", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000710", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000714", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000715", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000720", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000730", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000760", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569008402", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569008403", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868080000", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868080001", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868080002", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868080003", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001210", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001214", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001220", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864079510", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332024631", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332024671", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629268101", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629268102", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629268103", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629268104", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001514", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001520", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084061101", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084061111", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382051201", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382051205", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097092607", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69387010001", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69387010005", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452014220", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452014230", "ndc_label_name": "AMANTADINE 100 MG CAPSULE", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121064610", "ndc_label_name": "AMANTADINE 100 MG/10 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383080710", "ndc_label_name": "AMANTADINE 100 MG/10 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383080712", "ndc_label_name": "AMANTADINE 100 MG/10 ML SOLN", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121064616", "ndc_label_name": "AMANTADINE 50 MG/5 ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "46287001501", "ndc_label_name": "AMANTADINE 50 MG/5 ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383080716", "ndc_label_name": "AMANTADINE 50 MG/5 ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432009316", "ndc_label_name": "AMANTADINE 50 MG/5 ML SOLUTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00039022110", "ndc_label_name": "AMARYL 1 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00039022210", "ndc_label_name": "AMARYL 2 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00039022310", "ndc_label_name": "AMARYL 4 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00024542131", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00024542150", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999003730", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036310", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036315", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036320", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036321", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036325", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036330", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036360", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569382801", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289079206", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289079210", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289079212", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289079220", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289079230", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864070015", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629125601", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629125602", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629125603", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629125604", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629125605", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544001007", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544001010", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544001015", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544001020", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544001021", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544001030", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544001045", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544001053", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544001060", "ndc_label_name": "AMBIEN 10 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00024540131", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036210", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036215", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036220", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036230", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036260", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569382703", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289072906", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289072912", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289072930", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000907", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000914", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000915", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000920", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000930", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544000953", "ndc_label_name": "AMBIEN 5 MG TABLET", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00024552131", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353044330", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999076330", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959087030", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569576000", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569576001", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868542600", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868542601", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868542603", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868542604", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289020530", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760055130", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629314101", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629314102", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629314103", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629314104", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071036130", "ndc_label_name": "AMBIEN CR 12.5 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00024550131", "ndc_label_name": "AMBIEN CR 6.25 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999076430", "ndc_label_name": "AMBIEN CR 6.25 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868546100", "ndc_label_name": "AMBIEN CR 6.25 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868546101", "ndc_label_name": "AMBIEN CR 6.25 MG TABLET", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "552890572