{ "Profile_Information": { "public_name": "Pennsylvania", "state": "PENNSYLVANIA", "formulary_type": "Medicaid", "formulary_name": "194_763 2024 Medispan", "formulary_id": 22917, "formulary_version": 53, "formulary_effective_date": "01/07/2025" }, "Drug_Information": [ { "ndc": "00904676130", "ndc_label_name": "12 Hour Nasal Decongestant Solution 0.05 % Nasal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113038810", "ndc_label_name": "12 Hour Nasal Spray SOLUTION 0.05 % NASAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000051802", "ndc_label_name": "12HR Allergy & Congestion Tablet Extended Release 12 Hour 60-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000051801", "ndc_label_name": "12HR Allergy & Congestion Tablet Extended Release 12 Hour 60-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000058601", "ndc_label_name": "12HR Allergy Relief Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08517065736", "ndc_label_name": "1st Tier Unilet ComforTouch", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08517025736", "ndc_label_name": "1st Tier Unilet ComforTouch", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000060701", "ndc_label_name": "24HR Allergy & Congestion Reli Tablet Extended Release 24 Hour 180-240 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000036101", "ndc_label_name": "24HR Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000036103", "ndc_label_name": "24HR Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000036102", "ndc_label_name": "24HR Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000036104", "ndc_label_name": "24HR Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51672206200", "ndc_label_name": "3 Day Vaginal CREAM 2 % VAGINAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "73796026629", "ndc_label_name": "3 Series BP Monitor/Wrist DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000018001", "ndc_label_name": "8 Hour Arthritis Pain Reliever Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000018003", "ndc_label_name": "8 Hour Arthritis Pain Reliever Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000018004", "ndc_label_name": "8 Hour Arthritis Pain Reliever Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000018002", "ndc_label_name": "8 Hour Arthritis Pain Reliever Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917009173", "ndc_label_name": "A Thru Z Advantage TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007001", "ndc_label_name": "A Thru Z Select TABLET CHEWABLE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845005921", "ndc_label_name": "A-10000 Capsule 3 MG (10000 UT) Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11694085301", "ndc_label_name": "A-Caro-25 Capsule 25000 UNIT Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "31722056224", "ndc_label_name": "Abacavir Sulfate SOLUTION 20 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980040524", "ndc_label_name": "Abacavir Sulfate Solution 20 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862007360", "ndc_label_name": "Abacavir Sulfate TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079020401", "ndc_label_name": "Abacavir Sulfate TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904652304", "ndc_label_name": "Abacavir Sulfate Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722055760", "ndc_label_name": "Abacavir Sulfate TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079020406", "ndc_label_name": "Abacavir Sulfate TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904652306", "ndc_label_name": "Abacavir Sulfate Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378410591", "ndc_label_name": "Abacavir Sulfate TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097051403", "ndc_label_name": "Abacavir Sulfate Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569635100", "ndc_label_name": "Abacavir Sulfate Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084002121", "ndc_label_name": "Abacavir Sulfate TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904687406", "ndc_label_name": "Abacavir Sulfate Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904687404", "ndc_label_name": "Abacavir Sulfate Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084002111", "ndc_label_name": "Abacavir Sulfate TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505358306", "ndc_label_name": "Abacavir Sulfate Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64380071703", "ndc_label_name": "Abacavir Sulfate TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993048230", "ndc_label_name": "Abacavir Sulfate-lamiVUDine Tablet 600-300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35573040230", "ndc_label_name": "Abacavir Sulfate-lamiVUDine Tablet 600-300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862090030", "ndc_label_name": "Abacavir Sulfate-lamiVUDine Tablet 600-300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093538256", "ndc_label_name": "Abacavir Sulfate-lamiVUDine Tablet 600-300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862033530", "ndc_label_name": "Abacavir Sulfate-lamiVUDine Tablet 600-300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291011530", "ndc_label_name": "Abacavir Sulfate-lamiVUDine Tablet 600-300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097036202", "ndc_label_name": "Abacavir Sulfate-Lamivudine TABLET 600-300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180028806", "ndc_label_name": "Abacavir Sulfate-lamiVUDine Tablet 600-300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59572051501", "ndc_label_name": "Abecma Suspension 460000000 CELLS Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59572051503", "ndc_label_name": "Abecma Suspension 460000000 CELLS Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59572051502", "ndc_label_name": "Abecma Suspension 460000000 CELLS Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148010280", "ndc_label_name": "Abilify Asimtufii Prefilled Syringe 720 MG/2.4ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148011492", "ndc_label_name": "Abilify Asimtufii Prefilled Syringe 960 MG/3.2ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148011480", "ndc_label_name": "Abilify Asimtufii Prefilled Syringe 960 MG/3.2ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148004580", "ndc_label_name": "Abilify Maintena Prefilled Syringe 300 MG Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148007280", "ndc_label_name": "Abilify Maintena Prefilled Syringe 400 MG Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148001871", "ndc_label_name": "Abilify Maintena Suspension Reconstituted ER 300 MG Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148001870", "ndc_label_name": "Abilify Maintena Suspension Reconstituted ER 300 MG Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148001970", "ndc_label_name": "Abilify Maintena Suspension Reconstituted ER 400 MG Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148001971", "ndc_label_name": "Abilify Maintena Suspension Reconstituted ER 400 MG Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148003172", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003272", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148002972", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003372", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003472", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003072", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003172", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet Therapy Pack 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003272", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet Therapy Pack 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148002972", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet Therapy Pack 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003372", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet Therapy Pack 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003472", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet Therapy Pack 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003072", "ndc_label_name": "Abilify MyCite Maintenance Kit Tablet Therapy Pack 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003161", "ndc_label_name": "Abilify MyCite Starter Kit Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003261", "ndc_label_name": "Abilify MyCite Starter Kit Tablet 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148002961", "ndc_label_name": "Abilify MyCite Starter Kit Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003361", "ndc_label_name": "Abilify MyCite Starter Kit Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003461", "ndc_label_name": "Abilify MyCite Starter Kit Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003061", "ndc_label_name": "Abilify MyCite Starter Kit Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003161", "ndc_label_name": "Abilify MyCite Starter Kit Tablet Therapy Pack 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003261", "ndc_label_name": "Abilify MyCite Starter Kit Tablet Therapy Pack 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148002961", "ndc_label_name": "Abilify MyCite Starter Kit Tablet Therapy Pack 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003361", "ndc_label_name": "Abilify MyCite Starter Kit Tablet Therapy Pack 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003461", "ndc_label_name": "Abilify MyCite Starter Kit Tablet Therapy Pack 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003061", "ndc_label_name": "Abilify MyCite Starter Kit Tablet Therapy Pack 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148003185", "ndc_label_name": "Abilify MyCite Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148003285", "ndc_label_name": "Abilify MyCite Tablet 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148002985", "ndc_label_name": "Abilify MyCite Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148003385", "ndc_label_name": "Abilify MyCite Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148003485", "ndc_label_name": "Abilify MyCite Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148003085", "ndc_label_name": "Abilify MyCite Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959060530", "ndc_label_name": "Abilify Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353084815", "ndc_label_name": "Abilify Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353084816", "ndc_label_name": "Abilify Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289025130", "ndc_label_name": "Abilify Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148000813", "ndc_label_name": "Abilify TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353084845", "ndc_label_name": "Abilify Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148000913", "ndc_label_name": "Abilify TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071079415", "ndc_label_name": "Abilify TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629338604", "ndc_label_name": "Abilify Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629338601", "ndc_label_name": "Abilify Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629338602", "ndc_label_name": "Abilify Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148000613", "ndc_label_name": "Abilify TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353084916", "ndc_label_name": "Abilify Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49848002030", "ndc_label_name": "Abilify Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148001013", "ndc_label_name": "Abilify TABLET 20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353084945", "ndc_label_name": "Abilify Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353084915", "ndc_label_name": "Abilify Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353085015", "ndc_label_name": "Abilify Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353085045", "ndc_label_name": "Abilify Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353085099", "ndc_label_name": "Abilify Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49848002130", "ndc_label_name": "Abilify Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148001113", "ndc_label_name": "Abilify TABLET 30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289056630", "ndc_label_name": "Abilify TABLET 30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353085018", "ndc_label_name": "Abilify Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959060430", "ndc_label_name": "Abilify Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59148000713", "ndc_label_name": "Abilify TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49848001930", "ndc_label_name": "Abilify Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629338701", "ndc_label_name": "Abilify Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629338702", "ndc_label_name": "Abilify Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629338703", "ndc_label_name": "Abilify Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999081630", "ndc_label_name": "Abilify Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629338704", "ndc_label_name": "Abilify Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378692078", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143959721", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093112589", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687045521", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407018112", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505432701", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687045511", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64679002101", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291002412", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72205003092", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69238116507", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72606056601", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57894015512", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980041812", "ndc_label_name": "Abiraterone Acetate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72162215106", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505476406", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69238175406", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378692191", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60219175406", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591436560", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462088260", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291007360", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72603011101", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598046860", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "82293000210", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72205028560", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71921017706", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629943001", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "82009014060", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72606057301", "ndc_label_name": "Abiraterone Acetate Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68817013450", "ndc_label_name": "Abraxane Suspension Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069032501", "ndc_label_name": "Abrilada (1 Pen) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025032501", "ndc_label_name": "Abrilada (1 Pen) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069032502", "ndc_label_name": "Abrilada (2 Pen) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025032502", "ndc_label_name": "Abrilada (2 Pen) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069033302", "ndc_label_name": "Abrilada (2 Syringe) Prefilled Syringe Kit 20 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025033302", "ndc_label_name": "Abrilada (2 Syringe) Prefilled Syringe Kit 20 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069032802", "ndc_label_name": "Abrilada (2 Syringe) Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025032802", "ndc_label_name": "Abrilada (2 Syringe) Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069032501", "ndc_label_name": "Abrilada Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069033302", "ndc_label_name": "Abrilada Prefilled Syringe Kit 20 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069032802", "ndc_label_name": "Abrilada Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069034405", "ndc_label_name": "Abrysvo Solution Reconstituted 120 MCG/0.5ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069034401", "ndc_label_name": "Abrysvo Solution Reconstituted 120 MCG/0.5ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069246501", "ndc_label_name": "Abrysvo Solution Reconstituted 120 MCG/0.5ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069246510", "ndc_label_name": "Abrysvo Solution Reconstituted 120 MCG/0.5ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069246519", "ndc_label_name": "Abrysvo Solution Reconstituted 120 MCG/0.5ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011569", "ndc_label_name": "Absorica Capsule 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011531", "ndc_label_name": "Absorica Capsule 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118994003", "ndc_label_name": "Absorica Capsule 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011631", "ndc_label_name": "Absorica Capsule 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011669", "ndc_label_name": "Absorica Capsule 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631013331", "ndc_label_name": "Absorica Capsule 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631013369", "ndc_label_name": "Absorica Capsule 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011731", "ndc_label_name": "Absorica Capsule 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011769", "ndc_label_name": "Absorica Capsule 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631013469", "ndc_label_name": "Absorica Capsule 35 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631013431", "ndc_label_name": "Absorica Capsule 35 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011869", "ndc_label_name": "Absorica Capsule 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631011831", "ndc_label_name": "Absorica Capsule 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631000331", "ndc_label_name": "Absorica LD Capsule 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631000531", "ndc_label_name": "Absorica LD Capsule 24 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631000731", "ndc_label_name": "Absorica LD Capsule 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10631000231", "ndc_label_name": "Absorica LD Capsule 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42358040032", "ndc_label_name": "Abstral Tablet Sublingual 400 MCG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42358060032", "ndc_label_name": "Abstral Tablet Sublingual 600 MCG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42358080032", "ndc_label_name": "Abstral Tablet Sublingual 800 MCG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291010418", "ndc_label_name": "Acamprosate Calcium Tablet Delayed Release 333 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462043518", "ndc_label_name": "Acamprosate Calcium TABLET DELAYED RELEASE 333 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093535286", "ndc_label_name": "Acamprosate Calcium Tablet Delayed Release 333 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079024101", "ndc_label_name": "Acamprosate Calcium Tablet Delayed Release 333 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382056928", "ndc_label_name": "Acamprosate Calcium Tablet Delayed Release 333 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904721304", "ndc_label_name": "Acamprosate Calcium Tablet Delayed Release 333 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378633380", "ndc_label_name": "Acamprosate Calcium TABLET DELAYED RELEASE 333 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687012195", "ndc_label_name": "Acamprosate Calcium Tablet Delayed Release 333 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687012125", "ndc_label_name": "Acamprosate Calcium Tablet Delayed Release 333 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079024106", "ndc_label_name": "Acamprosate Calcium Tablet Delayed Release 333 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10135063632", "ndc_label_name": "Acamprosate Calcium TABLET DELAYED RELEASE 333 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13548013250", "ndc_label_name": "Acanya Gel 1.2-2.5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115115201", "ndc_label_name": "Acarbose TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054014225", "ndc_label_name": "Acarbose TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378282277", "ndc_label_name": "Acarbose TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155014905", "ndc_label_name": "Acarbose Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155014910", "ndc_label_name": "Acarbose Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781034201", "ndc_label_name": "Acarbose Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862021201", "ndc_label_name": "Acarbose TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16252052501", "ndc_label_name": "Acarbose Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291013290", "ndc_label_name": "Acarbose Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155014901", "ndc_label_name": "Acarbose Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64380076006", "ndc_label_name": "Acarbose Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543012211", "ndc_label_name": "Acarbose Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543012210", "ndc_label_name": "Acarbose Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054014025", "ndc_label_name": "Acarbose TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378282077", "ndc_label_name": "Acarbose TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155014701", "ndc_label_name": "Acarbose Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16252052301", "ndc_label_name": "Acarbose Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862021001", "ndc_label_name": "Acarbose TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155014705", "ndc_label_name": "Acarbose Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64380075806", "ndc_label_name": "Acarbose Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155014710", "ndc_label_name": "Acarbose Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291013090", "ndc_label_name": "Acarbose Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543012010", "ndc_label_name": "Acarbose Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781034001", "ndc_label_name": "Acarbose Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543012011", "ndc_label_name": "Acarbose Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155014805", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217013360", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378282177", "ndc_label_name": "Acarbose TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115115101", "ndc_label_name": "Acarbose TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054014125", "ndc_label_name": "Acarbose TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862021101", "ndc_label_name": "Acarbose TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155014801", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054014120", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155014810", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289017142", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16252052401", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543012110", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291013190", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217013330", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781034101", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217013390", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353095109", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64380075906", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543012111", "ndc_label_name": "Acarbose Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884058902", "ndc_label_name": "Accolate Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884001002", "ndc_label_name": "Accolate Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884001102", "ndc_label_name": "Accolate Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884059002", "ndc_label_name": "Accolate Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65702072310", "ndc_label_name": "Accu-Chek Aviva Plus Kit w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702010110", "ndc_label_name": "Accu-Chek Aviva Plus Kit w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702040710", "ndc_label_name": "Accu-Chek Aviva Plus STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702043810", "ndc_label_name": "Accu-Chek Aviva Plus Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702040810", "ndc_label_name": "Accu-Chek Aviva Plus STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702010710", "ndc_label_name": "Accu-Chek Aviva SOLUTION IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702028810", "ndc_label_name": "Accu-Chek FastClix Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702071310", "ndc_label_name": "Accu-Chek Guide Control Liquid In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702061710", "ndc_label_name": "Accu-Chek Guide Kit w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702072910", "ndc_label_name": "Accu-Chek Guide KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702073110", "ndc_label_name": "Accu-Chek Guide Me Kit w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702071210", "ndc_label_name": "Accu-Chek Guide Test Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702071910", "ndc_label_name": "Accu-Chek Guide Test Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702071110", "ndc_label_name": "Accu-Chek Guide Test Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50924007920", "ndc_label_name": "Accu-Chek Safe-T Pro Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50924095120", "ndc_label_name": "Accu-Chek Safe-T Pro Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702048810", "ndc_label_name": "Accu-Chek SmartView Control Liquid In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702049310", "ndc_label_name": "Accu-Chek SmartView STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702049210", "ndc_label_name": "Accu-Chek SmartView STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50924097110", "ndc_label_name": "Accu-Chek Softclix Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54868493100", "ndc_label_name": "Accu-Chek Softclix Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702012410", "ndc_label_name": "Accu-Chek Softclix Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702015610", "ndc_label_name": "Accu-Chek Softclix Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00071053023", "ndc_label_name": "Accupril TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874058190", "ndc_label_name": "Accupril Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874058110", "ndc_label_name": "Accupril Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00071053040", "ndc_label_name": "Accupril Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864085930", "ndc_label_name": "Accupril Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289055330", "ndc_label_name": "Accupril Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874058130", "ndc_label_name": "Accupril Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00071053240", "ndc_label_name": "Accupril Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289055430", "ndc_label_name": "Accupril Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864086930", "ndc_label_name": "Accupril Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00071053223", "ndc_label_name": "Accupril TABLET 20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00071053523", "ndc_label_name": "Accupril TABLET 40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874005890", "ndc_label_name": "Accupril Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289055530", "ndc_label_name": "Accupril Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864086330", "ndc_label_name": "Accupril Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629124201", "ndc_label_name": "Accupril Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874005815", "ndc_label_name": "Accupril Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874005810", "ndc_label_name": "Accupril Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874005830", "ndc_label_name": "Accupril Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874037930", "ndc_label_name": "Accupril Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00071052740", "ndc_label_name": "Accupril Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874037910", "ndc_label_name": "Accupril Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289055230", "ndc_label_name": "Accupril Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00071052723", "ndc_label_name": "Accupril TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00071022223", "ndc_label_name": "Accuretic Tablet 10-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00071022023", "ndc_label_name": "Accuretic Tablet 20-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00071022323", "ndc_label_name": "Accuretic Tablet 20-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65702027510", "ndc_label_name": "Accutrend Glucose Control SOLUTION IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702027410", "ndc_label_name": "Accutrend Glucose STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65702045610", "ndc_label_name": "Accutrend Glucose STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65162066910", "ndc_label_name": "Acebutolol HCl Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10135063001", "ndc_label_name": "Acebutolol HCl CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268005011", "ndc_label_name": "Acebutolol HCl CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268005015", "ndc_label_name": "Acebutolol HCl CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53746066901", "ndc_label_name": "Acebutolol HCl CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378120001", "ndc_label_name": "Acebutolol HCl Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629387101", "ndc_label_name": "Acebutolol HCl CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010190", "ndc_label_name": "Acebutolol HCl Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378140001", "ndc_label_name": "Acebutolol HCl Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162067010", "ndc_label_name": "Acebutolol HCl Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10135063101", "ndc_label_name": "Acebutolol HCl CAPSULE 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010290", "ndc_label_name": "Acebutolol HCl Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53746067001", "ndc_label_name": "Acebutolol HCl CAPSULE 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43292055574", "ndc_label_name": "Acerola C-500 TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802020326", "ndc_label_name": "Acetaminophen Childrens Suspension 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802020126", "ndc_label_name": "Acetaminophen Childrens Suspension 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904676620", "ndc_label_name": "Acetaminophen Childrens Suspension 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000031001", "ndc_label_name": "Acetaminophen Childrens TABLET CHEWABLE 160 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904688365", "ndc_label_name": "Acetaminophen ER Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68084077795", "ndc_label_name": "Acetaminophen ER Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68084077725", "ndc_label_name": "Acetaminophen ER Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50268005215", "ndc_label_name": "Acetaminophen ER Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50268005211", "ndc_label_name": "Acetaminophen ER Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015002", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904672080", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904672051", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015003", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904672059", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904672040", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904672024", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904673060", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015104", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904673059", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904673061", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000037303", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015301", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904673080", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904672060", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483034110", "ndc_label_name": "Acetaminophen Extra Strength TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000037301", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904674959", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000003601", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000037304", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000037302", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015001", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483034150", "ndc_label_name": "Acetaminophen Extra Strength TABLET 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015102", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015101", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483034101", "ndc_label_name": "Acetaminophen Extra Strength TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000037305", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015105", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000044601", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015103", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000044603", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000044602", "ndc_label_name": "Acetaminophen Extra Strength Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58657052016", "ndc_label_name": "Acetaminophen Liquid 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121065700", "ndc_label_name": "Acetaminophen Solution 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66689005499", "ndc_label_name": "Acetaminophen Solution 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121065705", "ndc_label_name": "Acetaminophen Solution 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121065721", "ndc_label_name": "Acetaminophen SOLUTION 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904673870", "ndc_label_name": "Acetaminophen Solution 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121131400", "ndc_label_name": "Acetaminophen Solution 325 MG/10.15ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904673971", "ndc_label_name": "Acetaminophen Solution 325 MG/10.15ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121131411", "ndc_label_name": "Acetaminophen Solution 325 MG/10.15ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66689005599", "ndc_label_name": "Acetaminophen Solution 325 MG/10.15ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904682076", "ndc_label_name": "Acetaminophen Solution 650 MG/20.3ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121197100", "ndc_label_name": "Acetaminophen Solution 650 MG/20.3ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121197121", "ndc_label_name": "Acetaminophen Solution 650 MG/20.3ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66689005699", "ndc_label_name": "Acetaminophen Solution 650 MG/20.3ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802073200", "ndc_label_name": "Acetaminophen SUPPOSITORY 120 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802073230", "ndc_label_name": "Acetaminophen SUPPOSITORY 120 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802073233", "ndc_label_name": "Acetaminophen SUPPOSITORY 120 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802073032", "ndc_label_name": "Acetaminophen Suppository 650 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802073030", "ndc_label_name": "Acetaminophen Suppository 650 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802073033", "ndc_label_name": "Acetaminophen Suppository 650 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904677361", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904671950", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070399", "ndc_label_name": "Acetaminophen TABLET 325 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483034010", "ndc_label_name": "Acetaminophen TABLET 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536116401", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483034001", "ndc_label_name": "Acetaminophen TABLET 325 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904671980", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070301", "ndc_label_name": "Acetaminophen TABLET 325 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015201", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63739044001", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015203", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904671960", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000037401", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015202", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070310", "ndc_label_name": "Acetaminophen TABLET 325 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000015204", "ndc_label_name": "Acetaminophen Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536117210", "ndc_label_name": "Acetaminophen Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000041001", "ndc_label_name": "Acetaminophen Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536117201", "ndc_label_name": "Acetaminophen Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070501", "ndc_label_name": "Acetaminophen TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070610", "ndc_label_name": "Acetaminophen TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070510", "ndc_label_name": "Acetaminophen TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000031201", "ndc_label_name": "Acetaminophen Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000031203", "ndc_label_name": "Acetaminophen Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000041002", "ndc_label_name": "Acetaminophen Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645070601", "ndc_label_name": "Acetaminophen TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000031202", "ndc_label_name": "Acetaminophen Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "64950037416", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121050404", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121050405", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "17856007905", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "17856007902", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121050400", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121100800", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999032304", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090021500", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50383033706", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121050416", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959014103", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50383033705", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "17856007901", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121050440", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959014104", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50383007916", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60432024516", "ndc_label_name": "Acetaminophen-Codeine Solution 120-12 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50383033913", "ndc_label_name": "Acetaminophen-Codeine Solution 300-30 MG/12.5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121100840", "ndc_label_name": "Acetaminophen-Codeine Solution 300-30 MG/12.5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121100812", "ndc_label_name": "Acetaminophen-Codeine Solution 300-30 MG/12.5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50383033912", "ndc_label_name": "Acetaminophen-Codeine Solution 300-30 MG/12.5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025924", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71930005412", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025902", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025912", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025920", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093005001", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406048301", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025915", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025950", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71930005452", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959020830", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603233721", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267022130", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107005801", "ndc_label_name": "Acetaminophen-Codeine TABLET 300-15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025930", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959020815", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025960", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294501", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025901", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025904", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702015", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702620", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406048423", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406048403", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093015001", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406048401", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406048462", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702081", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702610", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702630", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702020", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702085", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093015010", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702010", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702603", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702690", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702640", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702685", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702030", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702604", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406048410", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702606", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702691", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544010015", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000164", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000104", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702612", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544003215", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702012", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702615", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603233832", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "12634052680", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000190", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000130", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702660", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544003220", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702650", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000102", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000103", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000160", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000115", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000184", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440702681", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107005901", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107005999", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000107", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000114", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000172", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000140", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000190", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603233821", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000110", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000112", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000115", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000124", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006060", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000150", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353001070", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544010020", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000120", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000118", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000128", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000150", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090157301", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006050", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006030", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000120", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000125", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000121", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353001075", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000101", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090157400", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006090", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436322707", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006020", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000140", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000142", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006001", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000160", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000325", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079016101", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000324", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090193401", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000130", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000148", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090193301", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353001050", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000340", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000390", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000360", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000316", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353001060", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000100", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090193307", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353001090", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000350", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118056203", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187081530", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000345", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090157200", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353001045", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079016120", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090157202", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002010110", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118056206", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020206", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002010120", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090157203", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006024", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919002390", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090193302", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002010115", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919048430", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020210", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760046630", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090193304", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090157201", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919005360", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090193303", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54348001510", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020216", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020215", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919032830", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000300", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090157204", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919005371", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000328", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919002330", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020224", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020225", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919032871", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000302", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090157207", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020230", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000342", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020228", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020250", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020242", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020212", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000306", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090193300", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000124", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020220", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000110", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000130", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162003311", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020214", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000315", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090193500", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000184", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020260", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000215", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000270", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000190", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020290", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000320", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000304", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000260", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000120", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000230", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088250", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000191", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000106", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000330", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000310", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205000130", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000220", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000250", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084037201", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000285", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000112", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187081560", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000312", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025608", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000275", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788950606", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000375", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088220", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000115", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020205", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959000384", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335054502", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000280", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335054501", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002010130", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088254", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000240", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020208", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919002371", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335054505", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088230", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335054507", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919032890", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088260", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000255", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162003310", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187081520", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335054508", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088272", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000160", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629149410", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084037211", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088245", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000245", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020201", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011190", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088275", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000290", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020202", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025602", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088253", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000293", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020204", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025607", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088280", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088290", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020218", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335054509", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205000115", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788028506", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874020240", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011153", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788028503", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025601", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000140", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011160", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025600", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025605", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000253", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011180", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335054506", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025606", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088240", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335054500", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025603", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335054503", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088246", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011154", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011130", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71930005512", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088255", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71930005552", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011146", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544088270", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011170", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788950603", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011175", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025604", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025609", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335054504", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011145", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011172", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000248", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093035005", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000202", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406048501", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093035001", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406048505", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000212", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000256", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999002690", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603233928", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000208", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000221", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093035010", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603233921", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959044600", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000230", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959044650", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107006005", "ndc_label_name": "Acetaminophen-Codeine TABLET 300-60 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000214", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000230", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107006001", "ndc_label_name": "Acetaminophen-Codeine TABLET 300-60 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107006099", "ndc_label_name": "Acetaminophen-Codeine TABLET 300-60 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959044602", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000260", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959044660", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000210", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000220", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000240", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999002630", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000228", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959044630", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090301101", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629303101", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999002601", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000290", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000242", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919047260", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000200", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304056101", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919090590", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000360", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999002660", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999002640", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000260", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919090560", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959044624", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629303104", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629303105", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000380", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959044620", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919047290", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919027390", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026705", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629303103", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026701", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026708", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544047470", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026702", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026703", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629303102", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026750", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026740", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026715", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000230", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788973603", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026704", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026710", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026730", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026760", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000220", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026728", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000260", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788973606", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026712", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335033603", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544047460", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026790", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267000240", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544047453", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267100500", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788973609", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874026720", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335033606", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335033601", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000353", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000370", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544047480", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084037301", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71930005652", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71930005612", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544047490", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335070101", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788973601", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000390", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335070103", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084037311", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788973602", "ndc_label_name": "Acetaminophen-Codeine Tablet 300-60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687057821", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090594500", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729033101", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29033003001", "ndc_label_name": "AcetaZOLAMIDE ER CAPSULE EXTENDED RELEASE 12 HOUR 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135061260", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42571024301", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155012001", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090313200", "ndc_label_name": "AcetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155078701", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69367020901", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268004212", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268004211", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742023301", "ndc_label_name": "AcetaZOLAMIDE ER CAPSULE EXTENDED RELEASE 12 HOUR 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687057811", "ndc_label_name": "acetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332034931", "ndc_label_name": "AcetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710159101", "ndc_label_name": "AcetaZOLAMIDE ER Capsule Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155028701", "ndc_label_name": "AcetaZOLAMIDE TABLET 125 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672402201", "ndc_label_name": "AcetaZOLAMIDE TABLET 125 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380083306", "ndc_label_name": "AcetaZOLAMIDE TABLET 125 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155028801", "ndc_label_name": "AcetaZOLAMIDE TABLET 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672402301", "ndc_label_name": "AcetaZOLAMIDE TABLET 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904666361", "ndc_label_name": "AcetaZOLAMIDE Tablet 250 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084054111", "ndc_label_name": "acetaZOLAMIDE Tablet 250 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527105001", "ndc_label_name": "acetaZOLAMIDE Tablet 250 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380083406", "ndc_label_name": "AcetaZOLAMIDE TABLET 250 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084054101", "ndc_label_name": "acetaZOLAMIDE Tablet 250 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069310", "ndc_label_name": "Acetylcysteine SOLUTION 10 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409330703", "ndc_label_name": "Acetylcysteine SOLUTION 10 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517751003", "ndc_label_name": "Acetylcysteine SOLUTION 10 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517750425", "ndc_label_name": "Acetylcysteine SOLUTION 10 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069130", "ndc_label_name": "Acetylcysteine SOLUTION 10 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069504", "ndc_label_name": "Acetylcysteine SOLUTION 10 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517761003", "ndc_label_name": "Acetylcysteine SOLUTION 20 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069030", "ndc_label_name": "Acetylcysteine SOLUTION 20 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517760425", "ndc_label_name": "Acetylcysteine SOLUTION 20 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409330803", "ndc_label_name": "Acetylcysteine SOLUTION 20 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069404", "ndc_label_name": "Acetylcysteine SOLUTION 20 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069041", "ndc_label_name": "Acetylcysteine Solution 20 % Inhalation", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069444", "ndc_label_name": "Acetylcysteine Solution 20 % Inhalation", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517763003", "ndc_label_name": "Acetylcysteine SOLUTION 20 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069210", "ndc_label_name": "Acetylcysteine SOLUTION 20 % INHALATION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069044", "ndc_label_name": "Acetylcysteine Solution 20 % Inhalation", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323069441", "ndc_label_name": "Acetylcysteine Solution 20 % Inhalation", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150025930", "ndc_label_name": "Acetylcysteine SOLUTION 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478066030", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574080500", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574081530", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574080530", "ndc_label_name": "Acetylcysteine SOLUTION 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594011102", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069078801", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574081500", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323096321", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323096344", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323096341", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021081230", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594011101", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72611086004", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72611086001", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021081266", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323096330", "ndc_label_name": "Acetylcysteine SOLUTION 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069078804", "ndc_label_name": "Acetylcysteine Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51660003650", "ndc_label_name": "Acid Controller Max St Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917008767", "ndc_label_name": "Acid Controller Max St TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363003626", "ndc_label_name": "Acid Controller Max St Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363003650", "ndc_label_name": "Acid Controller Max St Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363003683", "ndc_label_name": "Acid Controller Max St Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660003626", "ndc_label_name": "Acid Controller Max St Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917007592", "ndc_label_name": "Acid Controller Max St Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917007602", "ndc_label_name": "Acid Controller Max St TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917007672", "ndc_label_name": "Acid Controller Max St TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904772714", "ndc_label_name": "Acid Gone SUSPENSION 95-358 MG/15ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000023201", "ndc_label_name": "Acid Reducer CAPSULE DELAYED RELEASE 20.6 (20 Base) MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000023202", "ndc_label_name": "Acid Reducer CAPSULE DELAYED RELEASE 20.6 (20 Base) MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000023203", "ndc_label_name": "Acid Reducer CAPSULE DELAYED RELEASE 20.6 (20 Base) MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205068063", "ndc_label_name": "Acid Reducer Complete Tablet Chewable 10-800-165 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205068163", "ndc_label_name": "Acid Reducer Complete Tablet Chewable 10-800-165 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000041601", "ndc_label_name": "Acid Reducer Complete Tablet Chewable 10-800-165 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800019471", "ndc_label_name": "Acid Reducer Maximum Strength TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800019402", "ndc_label_name": "Acid Reducer Maximum Strength TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113019402", "ndc_label_name": "Acid Reducer Maximum Strength TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800019451", "ndc_label_name": "Acid Reducer Maximum Strength Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031720", "ndc_label_name": "Acid Reducer Maximum Strength Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205086163", "ndc_label_name": "Acid Reducer Maximum Strength Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031721", "ndc_label_name": "Acid Reducer Maximum Strength Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "43292056397", "ndc_label_name": "Acid Reducer TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031134", "ndc_label_name": "Acid Reducer Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113014165", "ndc_label_name": "Acid Reducer TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800014172", "ndc_label_name": "Acid Reducer TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205061465", "ndc_label_name": "Acid Reducer Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800014165", "ndc_label_name": "Acid Reducer TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031133", "ndc_label_name": "Acid Reducer Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "23594021001", "ndc_label_name": "AcipHex Sprinkle Capsule Sprinkle 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13551021001", "ndc_label_name": "AcipHex Sprinkle Capsule Sprinkle 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23594020501", "ndc_label_name": "AcipHex Sprinkle Capsule Sprinkle 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13551020501", "ndc_label_name": "AcipHex Sprinkle CAPSULE SPRINKLE 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999044730", "ndc_label_name": "Aciphex Tablet Delayed Release 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000860", "ndc_label_name": "Aciphex Tablet Delayed Release 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62856024330", "ndc_label_name": "Aciphex Tablet Delayed Release 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358000830", "ndc_label_name": "Aciphex Tablet Delayed Release 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000445", "ndc_label_name": "Aciphex Tablet Delayed Release 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000480", "ndc_label_name": "Aciphex Tablet Delayed Release 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569498000", "ndc_label_name": "Aciphex Tablet Delayed Release 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000453", "ndc_label_name": "Aciphex Tablet Delayed Release 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591226330", "ndc_label_name": "Acitretin Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115166708", "ndc_label_name": "Acitretin Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093113556", "ndc_label_name": "Acitretin CAPSULE 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291008630", "ndc_label_name": "Acitretin CAPSULE 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42794008008", "ndc_label_name": "Acitretin CAPSULE 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115175008", "ndc_label_name": "Acitretin CAPSULE 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378702093", "ndc_label_name": "Acitretin CAPSULE 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993089430", "ndc_label_name": "Acitretin Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115175108", "ndc_label_name": "Acitretin Capsule 17.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291008730", "ndc_label_name": "Acitretin CAPSULE 17.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42794008108", "ndc_label_name": "Acitretin CAPSULE 17.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115166808", "ndc_label_name": "Acitretin Capsule 17.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093113856", "ndc_label_name": "Acitretin CAPSULE 17.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591226430", "ndc_label_name": "Acitretin Capsule 17.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115175308", "ndc_label_name": "Acitretin CAPSULE 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093113656", "ndc_label_name": "Acitretin CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115166908", "ndc_label_name": "Acitretin Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378702393", "ndc_label_name": "Acitretin CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591226630", "ndc_label_name": "Acitretin Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291008830", "ndc_label_name": "Acitretin CAPSULE 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42794008308", "ndc_label_name": "Acitretin CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993089630", "ndc_label_name": "Acitretin Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00536105656", "ndc_label_name": "Acne Medication 10 GEL 10 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090179200", "ndc_label_name": "Acne Medication 10 Gel 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536105875", "ndc_label_name": "Acne Medication 10 LOTION 10 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536112925", "ndc_label_name": "Acne Medication 2.5 Gel 2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569340600", "ndc_label_name": "Acne Medication 5 Gel 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090172000", "ndc_label_name": "Acne Medication 5 Gel 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536105556", "ndc_label_name": "Acne Medication 5 GEL 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536105775", "ndc_label_name": "Acne Medication 5 LOTION 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50242014301", "ndc_label_name": "Actemra ACTPen Solution Auto-Injector 162 MG/0.9ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50242013601", "ndc_label_name": "Actemra SOLUTION 200 MG/10ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50242013701", "ndc_label_name": "Actemra SOLUTION 400 MG/20ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50242013501", "ndc_label_name": "Actemra SOLUTION 80 MG/4ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50242013801", "ndc_label_name": "Actemra Solution Prefilled Syringe 162 MG/0.9ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63004871001", "ndc_label_name": "Acthar Gel 80 UNIT/ML Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51028000128", "ndc_label_name": "Acti-Lance 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638714120", "ndc_label_name": "Acti-Lance Lite Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638731125", "ndc_label_name": "Acti-Lance Lite Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638715510", "ndc_label_name": "Acti-Lance Lite Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638732150", "ndc_label_name": "Acti-Lance Lite Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08489715510", "ndc_label_name": "Acti-Lance Lite Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638731325", "ndc_label_name": "Acti-Lance Special Lancets 17G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638714320", "ndc_label_name": "Acti-Lance Special Lancets 17G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08489715710", "ndc_label_name": "Acti-Lance Special Lancets 17G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638732350", "ndc_label_name": "Acti-Lance Special Lancets 17G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638715710", "ndc_label_name": "Acti-Lance Special Lancets 17G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638731225", "ndc_label_name": "Acti-Lance Universal 23G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638715610", "ndc_label_name": "Acti-Lance Universal 23G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638714220", "ndc_label_name": "Acti-Lance Universal 23G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08489715610", "ndc_label_name": "Acti-Lance Universal 23G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08638732250", "ndc_label_name": "Acti-Lance Universal 23G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "75987011110", "ndc_label_name": "Actimmune Solution 100 MCG/0.5ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75987011111", "ndc_label_name": "Actimmune Solution 100 MCG/0.5ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42238011101", "ndc_label_name": "Actimmune Solution 2000000 UNIT/0.5ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42238011112", "ndc_label_name": "Actimmune SOLUTION 2000000 UNIT/0.5ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356046030", "ndc_label_name": "Actiq Lozenge On A Handle 1200 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459051230", "ndc_label_name": "Actiq Lozenge On A Handle 1200 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459051201", "ndc_label_name": "Actiq Lozenge On A Handle 1200 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459051601", "ndc_label_name": "Actiq Lozenge On A Handle 1600 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356046130", "ndc_label_name": "Actiq Lozenge On A Handle 1600 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459051630", "ndc_label_name": "Actiq Lozenge On A Handle 1600 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459050201", "ndc_label_name": "Actiq Lozenge On A Handle 200 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459050230", "ndc_label_name": "Actiq Lozenge On A Handle 200 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459050430", "ndc_label_name": "Actiq Lozenge On A Handle 400 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459050401", "ndc_label_name": "Actiq Lozenge On A Handle 400 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356045730", "ndc_label_name": "Actiq Lozenge On A Handle 400 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459050630", "ndc_label_name": "Actiq Lozenge On A Handle 600 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459050601", "ndc_label_name": "Actiq Lozenge On A Handle 600 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356045830", "ndc_label_name": "Actiq Lozenge On A Handle 600 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356045930", "ndc_label_name": "Actiq Lozenge On A Handle 800 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459050830", "ndc_label_name": "Actiq Lozenge On A Handle 800 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459050801", "ndc_label_name": "Actiq Lozenge On A Handle 800 MCG Buccal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50242008527", "ndc_label_name": "Activase SOLUTION RECONSTITUTED 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242004413", "ndc_label_name": "Activase SOLUTION RECONSTITUTED 50 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58809072530", "ndc_label_name": "Active FE Tablet 75-1.25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "28595043330", "ndc_label_name": "Active FE TABLET 75-1.25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60846020201", "ndc_label_name": "Activella Tablet 1-0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60846023201", "ndc_label_name": "Activella Tablet 1-0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00430047802", "ndc_label_name": "Actonel TABLET 150 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00430047801", "ndc_label_name": "Actonel TABLET 150 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00430047207", "ndc_label_name": "Actonel TABLET 35 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00430047203", "ndc_label_name": "Actonel TABLET 35 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569546200", "ndc_label_name": "Actonel Tablet 35 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64764015560", "ndc_label_name": "Actoplus Met Tablet 15-500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64764015860", "ndc_label_name": "Actoplus Met TABLET 15-850 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999044915", "ndc_label_name": "Actos TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544006553", "ndc_label_name": "Actos Tablet 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105015615", "ndc_label_name": "Actos TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569488000", "ndc_label_name": "Actos Tablet 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071040515", "ndc_label_name": "Actos TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544006560", "ndc_label_name": "Actos Tablet 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105015606", "ndc_label_name": "Actos TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105015603", "ndc_label_name": "Actos TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64764015104", "ndc_label_name": "Actos TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105015609", "ndc_label_name": "Actos TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105015601", "ndc_label_name": "Actos TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544006530", "ndc_label_name": "Actos Tablet 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569488100", "ndc_label_name": "Actos Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105015401", "ndc_label_name": "Actos Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544006645", "ndc_label_name": "Actos Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105015403", "ndc_label_name": "Actos Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105015415", "ndc_label_name": "Actos Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544006630", "ndc_label_name": "Actos Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544006660", "ndc_label_name": "Actos Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64764030114", "ndc_label_name": "Actos TABLET 30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105015406", "ndc_label_name": "Actos Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105015409", "ndc_label_name": "Actos Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071040615", "ndc_label_name": "Actos TABLET 30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071040715", "ndc_label_name": "Actos TABLET 45 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569488200", "ndc_label_name": "Actos Tablet 45 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64764045124", "ndc_label_name": "Actos TABLET 45 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00023927705", "ndc_label_name": "Acular LS SOLUTION 0.4 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999069505", "ndc_label_name": "Acular SOLUTION 0.5 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023218105", "ndc_label_name": "Acular SOLUTION 0.5 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569408300", "ndc_label_name": "Acular Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959011405", "ndc_label_name": "Acular Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569457300", "ndc_label_name": "Acular Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023350730", "ndc_label_name": "Acuvail Solution 0.45 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569634400", "ndc_label_name": "Acuvail Solution 0.45 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703081", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603005", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155022901", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603001", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603081", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894001", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894005", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703030", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544014625", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544010125", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010750", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603030", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703060", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544014630", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603060", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703083", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261041930", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261041990", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999038540", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063070135", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155014601", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291001750", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051750", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703085", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261041960", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063070150", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090059600", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082605", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291001701", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063088801", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011105", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904578961", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010701", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082650", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002024560", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051730", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999038510", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999038525", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040401", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155022905", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090059500", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063088882", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027330", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051735", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090059601", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002024530", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000625", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358000925", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006011", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999038515", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027335", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569448200", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002024525", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002024550", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010711", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090059507", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864087635", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090059501", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429071105", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569888001", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569888000", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011101", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788682703", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090059607", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040415", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002024535", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040420", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429001201", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027350", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011401", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69076014601", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006015", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040450", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569448201", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040470", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760065225", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027605", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304065205", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335028002", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051725", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205020950", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569448204", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000650", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040414", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429001205", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167601", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335028004", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348062025", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335024802", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569448206", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010701", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040460", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429071101", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167604", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335028007", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569448207", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335024807", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027310", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788682705", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116027135", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505004206", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040425", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335028009", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027305", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335028000", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027325", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335024800", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788969003", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011405", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040430", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335024804", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700065130", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335028003", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187018290", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335024809", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205024390", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919033130", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040435", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335047006", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167603", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335028005", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040410", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304065201", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335028001", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834012401", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040440", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167602", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040424", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167605", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335024803", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788682704", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335028006", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788682706", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000640", "ndc_label_name": "Acyclovir CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205020990", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335024805", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335024808", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335047007", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335047001", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335028008", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335047002", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335024801", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335024806", "ndc_label_name": "Acyclovir CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335047008", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335047005", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335047003", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335047000", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335047004", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335047009", "ndc_label_name": "Acyclovir Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093363020", "ndc_label_name": "Acyclovir Cream 5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802004475", "ndc_label_name": "Acyclovir Cream 5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378870049", "ndc_label_name": "Acyclovir OINTMENT 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591115930", "ndc_label_name": "Acyclovir OINTMENT 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378870006", "ndc_label_name": "Acyclovir OINTMENT 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668051502", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00713063015", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00168082530", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714066801", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00168082515", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079055067", "ndc_label_name": "Acyclovir OINTMENT 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00713063031", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668051501", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714088501", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714088502", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35573040331", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35573040315", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714066802", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332024830", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162083596", "ndc_label_name": "Acyclovir OINTMENT 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462074617", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079055068", "ndc_label_name": "Acyclovir OINTMENT 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63646030015", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672136001", "ndc_label_name": "Acyclovir OINTMENT 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382099201", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672136002", "ndc_label_name": "Acyclovir OINTMENT 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462074635", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332024815", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332024805", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63646030030", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162083594", "ndc_label_name": "Acyclovir OINTMENT 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382099204", "ndc_label_name": "Acyclovir Ointment 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55150015411", "ndc_label_name": "Acyclovir Sodium Solution 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323032509", "ndc_label_name": "Acyclovir Sodium Solution 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150015521", "ndc_label_name": "Acyclovir Sodium Solution 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382004801", "ndc_label_name": "Acyclovir Sodium Solution 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323032514", "ndc_label_name": "Acyclovir Sodium SOLUTION 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150015520", "ndc_label_name": "Acyclovir Sodium SOLUTION 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150015410", "ndc_label_name": "Acyclovir Sodium SOLUTION 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323032524", "ndc_label_name": "Acyclovir Sodium SOLUTION 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323032520", "ndc_label_name": "Acyclovir Sodium SOLUTION 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323032510", "ndc_label_name": "Acyclovir Sodium SOLUTION 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382004810", "ndc_label_name": "Acyclovir Sodium Solution 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382004910", "ndc_label_name": "Acyclovir Sodium Solution 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323032503", "ndc_label_name": "Acyclovir Sodium Solution 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70436003082", "ndc_label_name": "Acyclovir Sodium Solution 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382004901", "ndc_label_name": "Acyclovir Sodium Solution 50 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378871273", "ndc_label_name": "Acyclovir Suspension 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472008216", "ndc_label_name": "Acyclovir SUSPENSION 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155048551", "ndc_label_name": "Acyclovir Suspension 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651049347", "ndc_label_name": "Acyclovir Suspension 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383081016", "ndc_label_name": "Acyclovir Suspension 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70954018810", "ndc_label_name": "Acyclovir Suspension 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66689034216", "ndc_label_name": "Acyclovir Suspension 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722068147", "ndc_label_name": "Acyclovir Suspension 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72205017072", "ndc_label_name": "Acyclovir Suspension 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135080347", "ndc_label_name": "Acyclovir Suspension 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72888007917", "ndc_label_name": "Acyclovir Suspension 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894301", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703130", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544002725", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603105", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703185", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894305", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603181", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378025301", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603130", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703181", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544003940", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603125", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261049160", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603101", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155022705", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440103130", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904579061", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544003925", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090325005", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703125", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034025", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544010225", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261049130", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544010240", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544015124", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155022701", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090325400", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544015160", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092815", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544015130", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001015", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094214", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722077705", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001060", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006115", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063000101", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092860", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094260", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001028", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261049128", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356090315", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356090340", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054415", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034001", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090325002", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722077701", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001030", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261049190", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034004", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092825", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018821", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034015", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348062710", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010890", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356090330", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356090335", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034030", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090064404", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018828", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092804", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348062715", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034005", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356090360", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999008625", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034060", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090064409", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476502", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999008630", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046260", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034040", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010850", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090156702", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092830", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407014501", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569652700", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090064402", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118894308", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090064403", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999008600", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090325003", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092840", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054412", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046221", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054410", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874050020", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090156705", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999008690", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090325004", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999008621", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054425", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046235", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054450", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116024550", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090325009", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090064405", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006111", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090064501", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018830", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505530601", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429030901", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000725", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090325401", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090064406", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407014505", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090156706", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569888100", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505530608", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874050001", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788636008", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002000815", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090064500", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054430", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090325006", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046230", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167701", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000721", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788734204", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018825", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054401", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018815", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054440", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053935", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167702", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382079105", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788734208", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018860", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054421", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018850", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054460", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011201", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167707", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788734203", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335022508", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476503", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002000830", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348062730", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002000821", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919037030", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874050015", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788738202", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335032308", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476509", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053940", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476501", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002000860", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010801", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874050040", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69117001801", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834012205", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046205", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304050401", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476506", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476504", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788636004", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874050060", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205005630", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569476505", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046225", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739068210", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569888101", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569652701", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788636007", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788050407", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335032309", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046201", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700066415", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010811", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046240", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046212", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788734206", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788636002", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834012201", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289046215", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864060201", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382079101", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053930", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700066435", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788734209", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788636005", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864060230", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700066440", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167705", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788734202", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011205", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700066460", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69117001802", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788738205", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919065430", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429030905", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167706", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788734205", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187025315", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187025330", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205037130", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788738208", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874050021", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187025360", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788050403", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788738203", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874050030", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167703", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335032307", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934013130", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000715", "ndc_label_name": "Acyclovir TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167704", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788050406", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788738206", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267000730", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874050025", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788738204", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335022501", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788636003", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788738207", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335022502", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335022509", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788636006", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335022500", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335022504", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335022506", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788734201", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335022503", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335022507", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335032304", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788734207", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335032302", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335032301", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335032305", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335022505", "ndc_label_name": "Acyclovir Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335032303", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335032300", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335032306", "ndc_label_name": "Acyclovir TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703310", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603305", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603320", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603301", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722077801", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894705", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093894701", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155022805", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544020450", "ndc_label_name": "Acyclovir TABLET 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603310", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544002640", "ndc_label_name": "Acyclovir TABLET 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261022725", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010990", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703381", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440603381", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261022730", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002002735", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063058950", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544020435", "ndc_label_name": "Acyclovir TABLET 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261022735", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999023135", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544020440", "ndc_label_name": "Acyclovir TABLET 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703320", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291010950", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062935", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002002710", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261022716", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001130", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006211", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722077805", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440703385", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063058930", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700066335", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002002715", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063058910", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353093318", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002002750", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261022740", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544010340", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407014601", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505530701", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002002720", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090063802", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999023140", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217031325", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261022750", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155022801", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959067830", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011301", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002002725", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959067850", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090162402", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217031330", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063058935", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261022760", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062950", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167805", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217031335", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217031350", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062920", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569472402", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090063800", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261022790", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429031001", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040501", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217031340", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062910", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062930", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569888200", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006215", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001125", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429031005", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040510", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569888201", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700078635", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505530705", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167803", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407014605", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001135", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167802", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267039935", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289062940", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267039930", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919053035", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788898908", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864019125", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090162400", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040520", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010901", "ndc_label_name": "Acyclovir TABLET 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700083535", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788050508", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253010250", "ndc_label_name": "Acyclovir TABLET 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69117001901", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864019135", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959067840", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253010210", "ndc_label_name": "Acyclovir TABLET 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382079205", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442011305", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205038835", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084010911", "ndc_label_name": "Acyclovir TABLET 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69117001902", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040525", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002002730", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788737802", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788737803", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919000335", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002002760", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788737806", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934013235", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788050503", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569472400", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335031907", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788737808", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919053030", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187057406", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788737807", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205005330", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788737805", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167801", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788898904", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788898902", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187057425", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167804", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335031905", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335031908", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788898905", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040530", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304050501", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788898903", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335031902", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116024650", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874040535", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205005335", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335031909", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382079201", "ndc_label_name": "Acyclovir TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788050507", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335031901", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335069502", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788898906", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788737804", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335031904", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335031906", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788898907", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335069508", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335031903", "ndc_label_name": "Acyclovir Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834012301", "ndc_label_name": "Acyclovir TABLET 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834012305", "ndc_label_name": "Acyclovir TABLET 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023520690", "ndc_label_name": "Aczone Gel 7.5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023520660", "ndc_label_name": "Aczone Gel 7.5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16110052660", "ndc_label_name": "Aczone Gel 7.5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16110052690", "ndc_label_name": "Aczone Gel 7.5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49281040088", "ndc_label_name": "Adacel Suspension 5-2-15.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49281040015", "ndc_label_name": "Adacel Suspension 5-2-15.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49281040020", "ndc_label_name": "Adacel SUSPENSION 5-2-15.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49281040089", "ndc_label_name": "Adacel SUSPENSION 5-2-15.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49281040010", "ndc_label_name": "Adacel SUSPENSION 5-2-15.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49281040058", "ndc_label_name": "Adacel SUSPENSION 5-2-15.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078088361", "ndc_label_name": "Adakveo Solution 100 MG/10ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419070110", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864066914", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52427049401", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419070210", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 60 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289054330", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 60 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52427049501", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 60 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289054530", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 90 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544018560", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 90 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52427049601", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 90 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544018581", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 90 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544018582", "ndc_label_name": "Adalat CC Tablet Extended Release 24 Hour 90 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65219061299", "ndc_label_name": "Adalimumab-aacf (2 Pen) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65219062020", "ndc_label_name": "Adalimumab-aacf (2 Syringe) Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65219061299", "ndc_label_name": "Adalimumab-aacf Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65219061289", "ndc_label_name": "Adalimumab-aacf(CD/UC/HS Strt) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65219061269", "ndc_label_name": "Adalimumab-aacf(Ps/UV Starter) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72606002209", "ndc_label_name": "Adalimumab-aaty (1 Pen) Auto-Injector Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72606004004", "ndc_label_name": "Adalimumab-aaty (1 Pen) Auto-Injector Kit 80 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72606002210", "ndc_label_name": "Adalimumab-aaty (2 Pen) Auto-Injector Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72606004101", "ndc_label_name": "Adalimumab-aaty (2 Syringe) Prefilled Syringe Kit 20 MG/0.2ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72606002206", "ndc_label_name": "Adalimumab-aaty (2 Syringe) Prefilled Syringe Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61314032720", "ndc_label_name": "Adalimumab-adaz Solution Auto-Injector 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61314032796", "ndc_label_name": "Adalimumab-adaz Solution Auto-Injector 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61314033294", "ndc_label_name": "Adalimumab-adaz Solution Prefilled Syringe 20 MG/0.2ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61314033264", "ndc_label_name": "Adalimumab-adaz Solution Prefilled Syringe 20 MG/0.2ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61314032764", "ndc_label_name": "Adalimumab-adaz Solution Prefilled Syringe 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61314032794", "ndc_label_name": "Adalimumab-adaz Solution Prefilled Syringe 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597057550", "ndc_label_name": "Adalimumab-adbm (2 Pen) Auto-Injector Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "82009014422", "ndc_label_name": "Adalimumab-adbm (2 Pen) Auto-Injector Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "82009014822", "ndc_label_name": "Adalimumab-adbm (2 Pen) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597054522", "ndc_label_name": "Adalimumab-adbm (2 Pen) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597058589", "ndc_label_name": "Adalimumab-adbm (2 Syringe) Prefilled Syringe Kit 10 MG/0.2ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597055580", "ndc_label_name": "Adalimumab-adbm (2 Syringe) Prefilled Syringe Kit 20 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "82009014622", "ndc_label_name": "Adalimumab-adbm (2 Syringe) Prefilled Syringe Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597056520", "ndc_label_name": "Adalimumab-adbm (2 Syringe) Prefilled Syringe Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "82009015022", "ndc_label_name": "Adalimumab-adbm (2 Syringe) Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597059520", "ndc_label_name": "Adalimumab-adbm (2 Syringe) Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597054522", "ndc_label_name": "Adalimumab-adbm Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597058589", "ndc_label_name": "Adalimumab-adbm Prefilled Syringe Kit 10 MG/0.2ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597055580", "ndc_label_name": "Adalimumab-adbm Prefilled Syringe Kit 20 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597059520", "ndc_label_name": "Adalimumab-adbm Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597057560", "ndc_label_name": "Adalimumab-adbm(CD/UC/HS Strt) Auto-Injector Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597054566", "ndc_label_name": "Adalimumab-adbm(CD/UC/HS Strt) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597057540", "ndc_label_name": "Adalimumab-adbm(Ps/UV Starter) Auto-Injector Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597054544", "ndc_label_name": "Adalimumab-adbm(Ps/UV Starter) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49502041602", "ndc_label_name": "Adalimumab-fkjp (2 Pen) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "83257002232", "ndc_label_name": "Adalimumab-fkjp (2 Pen) Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "83257002042", "ndc_label_name": "Adalimumab-fkjp (2 Syringe) Prefilled Syringe Kit 20 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49502041702", "ndc_label_name": "Adalimumab-fkjp (2 Syringe) Prefilled Syringe Kit 20 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "83257002142", "ndc_label_name": "Adalimumab-fkjp (2 Syringe) Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49502041802", "ndc_label_name": "Adalimumab-fkjp (2 Syringe) Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49502041606", "ndc_label_name": "Adalimumab-fkjp Auto-Injector Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49502041706", "ndc_label_name": "Adalimumab-fkjp Prefilled Syringe Kit 20 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49502041806", "ndc_label_name": "Adalimumab-fkjp Prefilled Syringe Kit 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "82009015622", "ndc_label_name": "Adalimumab-ryvk (2 Pen) Auto-Injector Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "82009015822", "ndc_label_name": "Adalimumab-ryvk (2 Syringe) Prefilled Syringe Kit 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802045384", "ndc_label_name": "Adapalene CREAM 0.1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168042446", "ndc_label_name": "Adapalene CREAM 0.1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672415506", "ndc_label_name": "Adapalene Gel 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093630195", "ndc_label_name": "Adapalene Gel 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42546072045", "ndc_label_name": "Adapalene GEL 0.1 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569628800", "ndc_label_name": "Adapalene Gel 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118999904", "ndc_label_name": "Adapalene GEL 0.1 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462040355", "ndc_label_name": "Adapalene Gel 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993088445", "ndc_label_name": "Adapalene Gel 0.3 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781714270", "ndc_label_name": "Adapalene Gel 0.3 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781714219", "ndc_label_name": "Adapalene Gel 0.3 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993088448", "ndc_label_name": "Adapalene Gel 0.3 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472012645", "ndc_label_name": "Adapalene GEL 0.3 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672137706", "ndc_label_name": "Adapalene GEL 0.3 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672137709", "ndc_label_name": "Adapalene GEL 0.3 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69007091825", "ndc_label_name": "Adapalene Gel 0.3 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802084601", "ndc_label_name": "Adapalene-Benzoyl Peroxide GEL 0.1-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472031038", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.1-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462030147", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.1-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781718270", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.1-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672136403", "ndc_label_name": "Adapalene-Benzoyl Peroxide GEL 0.1-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993086948", "ndc_label_name": "Adapalene-Benzoyl Peroxide GEL 0.1-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672138409", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.3-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093630345", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.3-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802085345", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.3-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332066245", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.3-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00480315445", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.3-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629932201", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.3-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68308066245", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.3-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162143202", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.3-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72578011904", "ndc_label_name": "Adapalene-Benzoyl Peroxide Gel 0.3-2.5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57844051011", "ndc_label_name": "Adasuve Aerosol Powder Breath Activated 10 MG Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10885000305", "ndc_label_name": "Adasuve Aerosol Powder Breath Activated 10 MG Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10885000301", "ndc_label_name": "Adasuve Aerosol Powder Breath Activated 10 MG Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57844051055", "ndc_label_name": "Adasuve Aerosol Powder Breath Activated 10 MG Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50222035001", "ndc_label_name": "Adbry Solution Auto-Injector 300 MG/2ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50222035002", "ndc_label_name": "Adbry Solution Auto-Injector 300 MG/2ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50222034602", "ndc_label_name": "Adbry Solution Prefilled Syringe 150 MG/ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50222034604", "ndc_label_name": "Adbry Solution Prefilled Syringe 150 MG/ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51144005001", "ndc_label_name": "Adcetris Solution Reconstituted 50 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353007002", "ndc_label_name": "Adcirca Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353007004", "ndc_label_name": "Adcirca Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353007006", "ndc_label_name": "Adcirca Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66302046760", "ndc_label_name": "Adcirca Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353007012", "ndc_label_name": "Adcirca Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57844011001", "ndc_label_name": "Adderall TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629376801", "ndc_label_name": "Adderall Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57844011201", "ndc_label_name": "Adderall TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57844011501", "ndc_label_name": "Adderall TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629376901", "ndc_label_name": "Adderall Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57844012001", "ndc_label_name": "Adderall TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57844013001", "ndc_label_name": "Adderall TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57844010501", "ndc_label_name": "Adderall TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57844011701", "ndc_label_name": "Adderall TABLET 7.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356014790", "ndc_label_name": "Adderall XR CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54092038301", "ndc_label_name": "Adderall XR Capsule Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356014890", "ndc_label_name": "Adderall XR CAPSULE EXTENDED RELEASE 24 HOUR 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54092038501", "ndc_label_name": "Adderall XR CAPSULE EXTENDED RELEASE 24 HOUR 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54092038701", "ndc_label_name": "Adderall XR Capsule Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54092038901", "ndc_label_name": "Adderall XR Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54092039101", "ndc_label_name": "Adderall XR Capsule Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54092038101", "ndc_label_name": "Adderall XR Capsule Extended Release 24 Hour 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42794000308", "ndc_label_name": "Adefovir Dipivoxil TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505394703", "ndc_label_name": "Adefovir Dipivoxil Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025001", "ndc_label_name": "Adempas TABLET 0.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025003", "ndc_label_name": "Adempas Tablet 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025091", "ndc_label_name": "Adempas TABLET 0.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025103", "ndc_label_name": "Adempas Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025101", "ndc_label_name": "Adempas TABLET 1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025191", "ndc_label_name": "Adempas TABLET 1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025201", "ndc_label_name": "Adempas TABLET 1.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025203", "ndc_label_name": "Adempas Tablet 1.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025291", "ndc_label_name": "Adempas TABLET 1.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025303", "ndc_label_name": "Adempas Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025301", "ndc_label_name": "Adempas TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025391", "ndc_label_name": "Adempas TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025401", "ndc_label_name": "Adempas TABLET 2.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025403", "ndc_label_name": "Adempas Tablet 2.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419025491", "ndc_label_name": "Adempas TABLET 2.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67457085404", "ndc_label_name": "Adenosine Solution 12 MG/4ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021031804", "ndc_label_name": "Adenosine Solution 12 MG/4ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323065104", "ndc_label_name": "Adenosine SOLUTION 12 MG/4ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021030168", "ndc_label_name": "Adenosine SOLUTION 12 MG/4ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323065190", "ndc_label_name": "Adenosine Solution 12 MG/4ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323065101", "ndc_label_name": "Adenosine Solution 12 MG/4ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457085400", "ndc_label_name": "Adenosine Solution 12 MG/4ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323065123", "ndc_label_name": "Adenosine Solution 12 MG/4ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714055601", "ndc_label_name": "Adenosine Solution 3 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714099701", "ndc_label_name": "Adenosine Solution 3 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478054430", "ndc_label_name": "Adenosine Solution 3 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478054420", "ndc_label_name": "Adenosine Solution 3 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478095302", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323065189", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323065100", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478054202", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021030167", "ndc_label_name": "Adenosine SOLUTION 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021031802", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323065121", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478054225", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457085500", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323065102", "ndc_label_name": "Adenosine SOLUTION 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518073501", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518277801", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457085502", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72078003300", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518277800", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72078003302", "ndc_label_name": "Adenosine Solution 6 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57844001901", "ndc_label_name": "Adipex-P Capsule 37.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289037930", "ndc_label_name": "Adipex-P Tablet 37.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57844014001", "ndc_label_name": "Adipex-P Tablet 37.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72789017530", "ndc_label_name": "Adipex-P Tablet 37.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57844014056", "ndc_label_name": "Adipex-P Tablet 37.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08327007209", "ndc_label_name": "Adjustable Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "42167001110", "ndc_label_name": "Adjustable Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08347200001", "ndc_label_name": "Adjustable Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60913000301", "ndc_label_name": "Adjustable Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65038005601", "ndc_label_name": "Adlarity Patch Weekly 10 MG/DAY Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65038005603", "ndc_label_name": "Adlarity Patch Weekly 10 MG/DAY Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65038005503", "ndc_label_name": "Adlarity Patch Weekly 5 MG/DAY Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65038005501", "ndc_label_name": "Adlarity Patch Weekly 5 MG/DAY Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024574702", "ndc_label_name": "Adlyxin Solution Pen-Injector 20 MCG/0.2ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024574000", "ndc_label_name": "Adlyxin Solution Pen-Injector 20 MCG/0.2ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024574502", "ndc_label_name": "Adlyxin Starter Pack Pen-Injector Kit 10 & 20 MCG/0.2ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024592500", "ndc_label_name": "Admelog SoloStar Solution Pen-Injector 100 UNIT/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00024592505", "ndc_label_name": "Admelog SoloStar Solution Pen-Injector 100 UNIT/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00024592501", "ndc_label_name": "Admelog SoloStar Solution Pen-Injector 100 UNIT/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00024592605", "ndc_label_name": "Admelog Solution 100 UNIT/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00024592410", "ndc_label_name": "Admelog Solution 100 UNIT/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143936901", "ndc_label_name": "Adriamycin Solution 2 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143954810", "ndc_label_name": "Adriamycin Solution 2 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143937101", "ndc_label_name": "Adriamycin Solution 2 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143954910", "ndc_label_name": "Adriamycin Solution 2 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143937001", "ndc_label_name": "Adriamycin Solution 2 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143937201", "ndc_label_name": "Adriamycin Solution 2 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143954801", "ndc_label_name": "Adriamycin Solution 2 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143954701", "ndc_label_name": "Adriamycin Solution 2 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143954601", "ndc_label_name": "Adriamycin Solution 2 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143954901", "ndc_label_name": "Adriamycin Solution 2 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143927501", "ndc_label_name": "Adriamycin Solution Reconstituted 10 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143927701", "ndc_label_name": "Adriamycin Solution Reconstituted 50 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703301811", "ndc_label_name": "Adrucil Solution 2.5 GM/50ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703301511", "ndc_label_name": "Adrucil Solution 500 MG/10ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55566105000", "ndc_label_name": "Adstiladrin Suspension 300000000000 VP/ML Intravesical", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55566105001", "ndc_label_name": "Adstiladrin Suspension 300000000000 VP/ML Intravesical", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338000990", "ndc_label_name": "Adthyza Tablet 120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338011390", "ndc_label_name": "Adthyza Tablet 130 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338000590", "ndc_label_name": "Adthyza Tablet 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338001690", "ndc_label_name": "Adthyza Tablet 16.25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338000690", "ndc_label_name": "Adthyza Tablet 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338003290", "ndc_label_name": "Adthyza Tablet 32.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338000790", "ndc_label_name": "Adthyza Tablet 60 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338006590", "ndc_label_name": "Adthyza Tablet 65 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338000890", "ndc_label_name": "Adthyza Tablet 90 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338009790", "ndc_label_name": "Adthyza Tablet 97.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406010101", "ndc_label_name": "Aduhelm Solution 170 MG/1.7ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406010202", "ndc_label_name": "Aduhelm Solution 300 MG/3ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70000017802", "ndc_label_name": "Adult Aspirin Regimen Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000021801", "ndc_label_name": "Adult Aspirin Regimen Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000017801", "ndc_label_name": "Adult Aspirin Regimen Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000017803", "ndc_label_name": "Adult Aspirin Regimen Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000020301", "ndc_label_name": "Adult Aspirin Regimen Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000021802", "ndc_label_name": "Adult Aspirin Regimen Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917011462", "ndc_label_name": "Adult One Daily Gummies TABLET CHEWABLE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569524100", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 100-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090431000", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 100-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518051400", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 100-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261087301", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 100-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173069504", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 100-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090073000", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 100-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173069500", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 100-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173069600", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090073100", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173069604", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518053800", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569524200", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261087401", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090450200", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090073200", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 500-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090450500", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 500-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173069704", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 500-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173069700", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 500-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569524300", "ndc_label_name": "Advair Diskus Aerosol Powder Breath Activated 500-50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173071620", "ndc_label_name": "Advair HFA Aerosol 115-21 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173071622", "ndc_label_name": "Advair HFA Aerosol 115-21 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173071761", "ndc_label_name": "Advair HFA Aerosol 230-21 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173071722", "ndc_label_name": "Advair HFA Aerosol 230-21 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173071720", "ndc_label_name": "Advair HFA Aerosol 230-21 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173071522", "ndc_label_name": "Advair HFA Aerosol 45-21 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173071520", "ndc_label_name": "Advair HFA Aerosol 45-21 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08317420005", "ndc_label_name": "Advance Intuition Control Liquid Normal In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317410602", "ndc_label_name": "Advance Micro-Draw Control Liquid In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317410501", "ndc_label_name": "Advance Micro-Draw Normal Liquid In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917018877", "ndc_label_name": "Advanced Mobile Lancet", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55571093592", "ndc_label_name": "Advanced Multi EA TABLET CHEWABLE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917016962", "ndc_label_name": "Advantage Care Electrolyte Ped SOLUTION Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00944305302", "ndc_label_name": "Advate Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944305402", "ndc_label_name": "Advate Solution Reconstituted 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944296310", "ndc_label_name": "Advate Solution Reconstituted 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944292402", "ndc_label_name": "Advate Solution Reconstituted 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944304510", "ndc_label_name": "Advate Solution Reconstituted 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944305102", "ndc_label_name": "Advate Solution Reconstituted 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944304610", "ndc_label_name": "Advate Solution Reconstituted 3000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944294810", "ndc_label_name": "Advate Solution Reconstituted 4000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944304710", "ndc_label_name": "Advate Solution Reconstituted 4000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944305202", "ndc_label_name": "Advate Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00573176913", "ndc_label_name": "Advil Liqui-Gels minis Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00573176920", "ndc_label_name": "Advil Liqui-Gels minis Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00573176980", "ndc_label_name": "Advil Liqui-Gels minis Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60010003310", "ndc_label_name": "Advin COVID-19 Antigen Test Kit In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60010003312", "ndc_label_name": "Advin COVID-19 Antigen Test Kit In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000140", "ndc_label_name": "Advocate Arm BPM DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000153", "ndc_label_name": "Advocate Arm BPM DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000141", "ndc_label_name": "Advocate Arm BPM DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000102", "ndc_label_name": "Advocate Blood Glucose Monitor DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000107", "ndc_label_name": "Advocate Blood Glucose Monitor DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000119", "ndc_label_name": "Advocate Blood Glucose System Kit w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000134", "ndc_label_name": "Advocate Blood Glucose System KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000104", "ndc_label_name": "Advocate Control Solution Liquid High In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000101", "ndc_label_name": "Advocate Control Solution Liquid Low In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000109", "ndc_label_name": "Advocate Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000106", "ndc_label_name": "Advocate Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000110", "ndc_label_name": "Advocate Lancets 30G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "52982000604", "ndc_label_name": "Advocate Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000105", "ndc_label_name": "Advocate Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000197", "ndc_label_name": "Advocate Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "52982000600", "ndc_label_name": "Advocate Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000103", "ndc_label_name": "Advocate Rapid-Safe Lancing", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000111", "ndc_label_name": "Advocate Redi-Code DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000112", "ndc_label_name": "Advocate Redi-Code DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000136", "ndc_label_name": "Advocate Redi-Code KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000113", "ndc_label_name": "Advocate Redi-Code STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000126", "ndc_label_name": "Advocate Redi-Code STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000124", "ndc_label_name": "Advocate Redi-Code STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000139", "ndc_label_name": "Advocate Redi-Code STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000157", "ndc_label_name": "Advocate Redi-Code STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000160", "ndc_label_name": "Advocate Redi-Code+ Control SOLUTION High IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000158", "ndc_label_name": "Advocate Redi-Code+ Control SOLUTION Low IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000188", "ndc_label_name": "Advocate Redi-Code+ DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000156", "ndc_label_name": "Advocate Redi-Code+ DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000133", "ndc_label_name": "Advocate Redi-Code+ Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000187", "ndc_label_name": "Advocate Redi-Code+ Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000118", "ndc_label_name": "Advocate Safety Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000192", "ndc_label_name": "Advocate Safety Lancets 26G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000100", "ndc_label_name": "Advocate Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94046000116", "ndc_label_name": "Advocate Wrist BP Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00944425602", "ndc_label_name": "Adynovate Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944462401", "ndc_label_name": "Adynovate SOLUTION RECONSTITUTED 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944462701", "ndc_label_name": "Adynovate SOLUTION RECONSTITUTED 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944462702", "ndc_label_name": "Adynovate SOLUTION RECONSTITUTED 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944462501", "ndc_label_name": "Adynovate SOLUTION RECONSTITUTED 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944425802", "ndc_label_name": "Adynovate Solution Reconstituted 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944425202", "ndc_label_name": "Adynovate Solution Reconstituted 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944462201", "ndc_label_name": "Adynovate SOLUTION RECONSTITUTED 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944462802", "ndc_label_name": "Adynovate SOLUTION RECONSTITUTED 3000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944462801", "ndc_label_name": "Adynovate SOLUTION RECONSTITUTED 3000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944425402", "ndc_label_name": "Adynovate Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944462301", "ndc_label_name": "Adynovate SOLUTION RECONSTITUTED 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944462601", "ndc_label_name": "Adynovate SOLUTION RECONSTITUTED 750 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944462602", "ndc_label_name": "Adynovate SOLUTION RECONSTITUTED 750 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70165002030", "ndc_label_name": "Adzenys XR-ODT Tablet Extended Release Dispersible 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70165002530", "ndc_label_name": "Adzenys XR-ODT Tablet Extended Release Dispersible 15.7 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70165003030", "ndc_label_name": "Adzenys XR-ODT Tablet Extended Release Dispersible 18.8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70165000530", "ndc_label_name": "Adzenys XR-ODT Tablet Extended Release Dispersible 3.1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70165001030", "ndc_label_name": "Adzenys XR-ODT Tablet Extended Release Dispersible 6.3 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70165001530", "ndc_label_name": "Adzenys XR-ODT Tablet Extended Release Dispersible 9.4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64764014505", "ndc_label_name": "Adzynma Kit 1500 UNIT Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64764014005", "ndc_label_name": "Adzynma Kit 500 UNIT Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71068000110", "ndc_label_name": "Aemcolo Tablet Delayed Release 194 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71068000111", "ndc_label_name": "Aemcolo Tablet Delayed Release 194 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57841120001", "ndc_label_name": "Aemcolo Tablet Delayed Release 194 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351098810", "ndc_label_name": "AeroChamber Mini Chamber DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351098510", "ndc_label_name": "AeroChamber MV", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456315467", "ndc_label_name": "AeroChamber Plus Flo-Vu", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090034800", "ndc_label_name": "AeroChamber Plus Flo-Vu", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351080810", "ndc_label_name": "AeroChamber Plus Flo-Vu Large", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456074613", "ndc_label_name": "AeroChamber Plus Flo-Vu Large", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351078810", "ndc_label_name": "AeroChamber Plus Flo-Vu Medium", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456074413", "ndc_label_name": "AeroChamber Plus Flo-Vu Small", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351088810", "ndc_label_name": "AeroChamber Plus Flo-Vu Small", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456074513", "ndc_label_name": "AeroChamber Plus Flo-Vu w/Mask", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351079850", "ndc_label_name": "AeroChamber Plus Flow VU", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351079810", "ndc_label_name": "AeroChamber Plus Flow VU", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351079510", "ndc_label_name": "AeroChamber w/FLOWSIGnal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351079710", "ndc_label_name": "AeroChamber Z-Stat Plus", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351079750", "ndc_label_name": "AeroChamber Z-Stat Plus Chambr", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351080710", "ndc_label_name": "AeroChamber Z-Stat Plus/Large", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351078710", "ndc_label_name": "AeroChamber Z-Stat Plus/Medium", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351088710", "ndc_label_name": "AeroChamber Z-Stat Plus/Small", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351085850", "ndc_label_name": "AeroVent Plus DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "04351085810", "ndc_label_name": "AeroVent Plus DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078062651", "ndc_label_name": "Afinitor Disperz Tablet Soluble 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062661", "ndc_label_name": "Afinitor Disperz Tablet Soluble 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062751", "ndc_label_name": "Afinitor Disperz Tablet Soluble 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062761", "ndc_label_name": "Afinitor Disperz Tablet Soluble 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062851", "ndc_label_name": "Afinitor Disperz Tablet Soluble 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078062861", "ndc_label_name": "Afinitor Disperz Tablet Soluble 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078056751", "ndc_label_name": "Afinitor Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078056761", "ndc_label_name": "Afinitor Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078059451", "ndc_label_name": "Afinitor Tablet 2.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078059461", "ndc_label_name": "Afinitor Tablet 2.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078056651", "ndc_label_name": "Afinitor Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078056661", "ndc_label_name": "Afinitor Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078062051", "ndc_label_name": "Afinitor Tablet 7.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078062061", "ndc_label_name": "Afinitor Tablet 7.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862084988", "ndc_label_name": "Afirmelle Tablet 0.1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862084928", "ndc_label_name": "Afirmelle Tablet 0.1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33332002403", "ndc_label_name": "Afluria Preservative Free Suspension Prefilled Syringe 0.5 ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33332002404", "ndc_label_name": "Afluria Preservative Free Suspension Prefilled Syringe 0.5 ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33332012410", "ndc_label_name": "Afluria Suspension Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33332012411", "ndc_label_name": "Afluria Suspension Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47918089190", "ndc_label_name": "Afrezza POWDER 12 UNIT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47918087490", "ndc_label_name": "Afrezza POWDER 4 UNIT INHALATION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47918090218", "ndc_label_name": "Afrezza Powder 60x4 &60x8 & 60x12 UNIT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47918087890", "ndc_label_name": "Afrezza POWDER 8 UNIT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47918088018", "ndc_label_name": "Afrezza Powder 90 x 4 UNIT & 90x8 UNIT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47918089818", "ndc_label_name": "Afrezza Powder 90 x 8 UNIT & 90x12 UNIT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00085068301", "ndc_label_name": "Afrin Saline Nasal Mist Solution 0.65 % Nasal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "69911047602", "ndc_label_name": "Afstyla KIT 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69911048002", "ndc_label_name": "Afstyla KIT 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69911047702", "ndc_label_name": "Afstyla KIT 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69911047402", "ndc_label_name": "Afstyla KIT 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69911048102", "ndc_label_name": "Afstyla KIT 2500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69911047802", "ndc_label_name": "Afstyla KIT 3000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69911047502", "ndc_label_name": "Afstyla KIT 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69536010388", "ndc_label_name": "Aftera Tablet 1.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51285010388", "ndc_label_name": "Aftera Tablet 1.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "08554402501", "ndc_label_name": "AgaMatrix AMP DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554403601", "ndc_label_name": "AgaMatrix AMP Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554201101", "ndc_label_name": "AgaMatrix Control SOLUTION High IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554376402", "ndc_label_name": "AgaMatrix Control SOLUTION IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554133301", "ndc_label_name": "AgaMatrix Control SOLUTION Normal IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554232001", "ndc_label_name": "AgaMatrix Jazz Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554318802", "ndc_label_name": "AgaMatrix Jazz Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554229701", "ndc_label_name": "AgaMatrix Jazz Wireless 2 KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554386401", "ndc_label_name": "AgaMatrix Presto KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554362901", "ndc_label_name": "AgaMatrix Presto KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554264901", "ndc_label_name": "AgaMatrix Presto KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554408801", "ndc_label_name": "AgaMatrix Presto Pro Meter DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554333702", "ndc_label_name": "AgaMatrix Presto Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08554197101", "ndc_label_name": "AgaMatrix Ultra-Thin Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69616026438", "ndc_label_name": "Agamree Suspension 40 MG/ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "25208000104", "ndc_label_name": "Aggrastat CONCENTRATE 3.75 MG/15ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25208090104", "ndc_label_name": "Aggrastat Concentrate 3.75 MG/15ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25208000202", "ndc_label_name": "Aggrastat Solution 12.5-0.9 MG/250ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25208090202", "ndc_label_name": "Aggrastat Solution 12.5-0.9 MG/250ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25208000203", "ndc_label_name": "Aggrastat Solution 5-0.9 MG/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25208090201", "ndc_label_name": "Aggrastat Solution 5-0.9 MG/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25208000201", "ndc_label_name": "Aggrastat Solution 5-0.9 MG/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513084300", "ndc_label_name": "Aimovig Solution Auto-Injector 140 MG/ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513084301", "ndc_label_name": "Aimovig Solution Auto-Injector 140 MG/ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513084101", "ndc_label_name": "Aimovig Solution Auto-Injector 70 MG/ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51709000605", "ndc_label_name": "Aimsco Lubricated", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "89134321001", "ndc_label_name": "Aimsco Twist Lancets 32G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "89134331001", "ndc_label_name": "Aimsco Twist Lancets 33G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "59310012906", "ndc_label_name": "AirDuo Digihaler Aerosol Powder Breath Activated 113-14 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59310013606", "ndc_label_name": "AirDuo Digihaler Aerosol Powder Breath Activated 232-14 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59310011106", "ndc_label_name": "AirDuo Digihaler Aerosol Powder Breath Activated 55-14 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59310081206", "ndc_label_name": "AirDuo RespiClick 113/14 Aerosol Powder Breath Activated 113-14 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59310082206", "ndc_label_name": "AirDuo RespiClick 232/14 Aerosol Powder Breath Activated 232-14 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59310080506", "ndc_label_name": "AirDuo RespiClick 55/14 Aerosol Powder Breath Activated 55-14 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310908028", "ndc_label_name": "Airsupra Aerosol 90-80 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310908012", "ndc_label_name": "Airsupra Aerosol 90-80 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08462130045", "ndc_label_name": "Airzone Peak Flow Meter DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "83490031024", "ndc_label_name": "Airzone Peak Flow Meter Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51759020211", "ndc_label_name": "Ajovy Solution Auto-Injector 225 MG/1.5ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51759020222", "ndc_label_name": "Ajovy Solution Auto-Injector 225 MG/1.5ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51759020210", "ndc_label_name": "Ajovy Solution Auto-Injector 225 MG/1.5ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51759020410", "ndc_label_name": "Ajovy Solution Prefilled Syringe 225 MG/1.5ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51759020411", "ndc_label_name": "Ajovy Solution Prefilled Syringe 225 MG/1.5ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57894010060", "ndc_label_name": "Akeega Tablet 100-500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57894005060", "ndc_label_name": "Akeega Tablet 50-500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00299593545", "ndc_label_name": "Aklief Cream 0.005 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69639010601", "ndc_label_name": "Akynzeo (Ready-to-Use) Solution 235-0.25 MG/20ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69639010501", "ndc_label_name": "Akynzeo (To-be-Diluted) Solution 235-0.25 MG/20ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69639010101", "ndc_label_name": "Akynzeo CAPSULE 300-0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62856079601", "ndc_label_name": "Akynzeo CAPSULE 300-0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69639010201", "ndc_label_name": "Akynzeo Solution Reconstituted 235-0.25 MG Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "24208060105", "ndc_label_name": "Alaway Childrens Allergy Solution 0.035 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "24208060110", "ndc_label_name": "Alaway Solution 0.035 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54505005522", "ndc_label_name": "Albendazole Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42799011002", "ndc_label_name": "Albendazole Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591271202", "ndc_label_name": "Albendazole Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714090701", "ndc_label_name": "Albendazole Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70710102108", "ndc_label_name": "Albendazole Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722093502", "ndc_label_name": "Albendazole Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097023772", "ndc_label_name": "Albendazole Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08620219121", "ndc_label_name": "Albustix Strip In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00093317431", "ndc_label_name": "Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802008801", "ndc_label_name": "Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993001968", "ndc_label_name": "Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788735302", "ndc_label_name": "Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090413700", "ndc_label_name": "Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00254100752", "ndc_label_name": "Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205021185", "ndc_label_name": "Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00487950125", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827052", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827055", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487950103", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827091", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591379783", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781715586", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591379730", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487950160", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591379760", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378827093", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687039583", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487950101", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261078901", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999034425", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090051601", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487950102", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090051600", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781715564", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55154435905", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781715529", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569389901", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687039579", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788013402", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569389900", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76204020030", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071419902", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76204020060", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76204020001", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76204020025", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383074120", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959074120", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69374033005", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090051700", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135082984", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "73177014632", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "73177016333", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "73177016332", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69374030920", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "73177014633", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65302052815", "ndc_label_name": "Albuterol Sulfate Nebulization Solution (5 MG/ML) 0.5% Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487030102", "ndc_label_name": "Albuterol Sulfate Nebulization Solution 0.63 MG/3ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487030101", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION 0.63 MG/3ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378699152", "ndc_label_name": "Albuterol Sulfate Nebulization Solution 0.63 MG/3ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591346753", "ndc_label_name": "Albuterol Sulfate Nebulization Solution 0.63 MG/3ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591346853", "ndc_label_name": "Albuterol Sulfate Nebulization Solution 1.25 MG/3ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378699252", "ndc_label_name": "Albuterol Sulfate Nebulization Solution 1.25 MG/3ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487990401", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION 1.25 MG/3ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487990402", "ndc_label_name": "Albuterol Sulfate Nebulization Solution 1.25 MG/3ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378699298", "ndc_label_name": "Albuterol Sulfate Nebulization Solution 1.25 MG/3ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487990425", "ndc_label_name": "Albuterol Sulfate NEBULIZATION SOLUTION 1.25 MG/3ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487990130", "ndc_label_name": "Albuterol Sulfate Nebulization Solution 2.5 MG/0.5ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00487990102", "ndc_label_name": "Albuterol Sulfate Nebulization Solution 2.5 MG/0.5ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66689010016", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959015303", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135018941", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383074016", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472082516", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959015306", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135018947", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162206402", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959015309", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70752010212", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788739004", "ndc_label_name": "Albuterol Sulfate Syrup 2 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440704524", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378025501", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874037701", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999090102", "ndc_label_name": "Albuterol Sulfate TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378025505", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079065720", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440704530", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569340900", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079065701", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489017605", "ndc_label_name": "Albuterol Sulfate TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874037712", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001030", "ndc_label_name": "Albuterol Sulfate TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289036324", "ndc_label_name": "Albuterol Sulfate TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874037724", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289036330", "ndc_label_name": "Albuterol Sulfate TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084094995", "ndc_label_name": "Albuterol Sulfate TABLET 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217001730", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874037730", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788025503", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084094925", "ndc_label_name": "Albuterol Sulfate TABLET 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489017601", "ndc_label_name": "Albuterol Sulfate TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238134401", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629263801", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289036320", "ndc_label_name": "Albuterol Sulfate TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980044201", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629263802", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543029010", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874037715", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874037720", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543029018", "ndc_label_name": "Albuterol Sulfate Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378057201", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489017705", "ndc_label_name": "Albuterol Sulfate TABLET 4 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289004530", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378057205", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874048524", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440704630", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959090620", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079065820", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079065801", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569287401", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874048515", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084095225", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980044301", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874048520", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629273601", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489017701", "ndc_label_name": "Albuterol Sulfate TABLET 4 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874048503", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874048501", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543029118", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874048512", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238134501", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874048530", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543029110", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874048560", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084095295", "ndc_label_name": "Albuterol Sulfate Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672130601", "ndc_label_name": "Alclometasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026315", "ndc_label_name": "Alclometasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462030047", "ndc_label_name": "Alclometasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026360", "ndc_label_name": "Alclometasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672130606", "ndc_label_name": "Alclometasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672130603", "ndc_label_name": "Alclometasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026345", "ndc_label_name": "Alclometasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462030017", "ndc_label_name": "Alclometasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462030065", "ndc_label_name": "Alclometasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026460", "ndc_label_name": "Alclometasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672131601", "ndc_label_name": "Alclometasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026415", "ndc_label_name": "Alclometasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462029947", "ndc_label_name": "Alclometasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672131603", "ndc_label_name": "Alclometasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026445", "ndc_label_name": "Alclometasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672131606", "ndc_label_name": "Alclometasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462029965", "ndc_label_name": "Alclometasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462029917", "ndc_label_name": "Alclometasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "38779754501", "ndc_label_name": "Alcoh-Glove Contoured Wipe PAD", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "38779754401", "ndc_label_name": "Alcoh-Wipe SHEET", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57513000645", "ndc_label_name": "Alcohol Pads PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "91237000128", "ndc_label_name": "Alcohol Pads PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "67777012113", "ndc_label_name": "Alcohol Prep PAD", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "67777012114", "ndc_label_name": "Alcohol Prep PAD", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "67777012116", "ndc_label_name": "Alcohol Prep PAD", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "62850000001", "ndc_label_name": "Alcohol Prep Pad", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69967000201", "ndc_label_name": "Alcohol Prep Pad", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "63517060001", "ndc_label_name": "Alcohol Prep PAD", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60913000801", "ndc_label_name": "Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68113099601", "ndc_label_name": "Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60913000702", "ndc_label_name": "Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520080930", "ndc_label_name": "Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536750001", "ndc_label_name": "Alcohol Prep PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536110301", "ndc_label_name": "Alcohol Prep PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917014296", "ndc_label_name": "Alcohol Prep PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "42167000630", "ndc_label_name": "Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "40986001290", "ndc_label_name": "Alcohol Prep PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "32671000701", "ndc_label_name": "Alcohol Prep PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60913000601", "ndc_label_name": "Alcohol Prep PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68113011401", "ndc_label_name": "Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60913001702", "ndc_label_name": "Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60913000902", "ndc_label_name": "Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60913001802", "ndc_label_name": "Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000011201", "ndc_label_name": "Alcohol Swabs PAD", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "62451999810", "ndc_label_name": "Alcohol Swabs Pad", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917008216", "ndc_label_name": "Alcohol Swabs PAD", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904427760", "ndc_label_name": "Alcohol Swabs PAD", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205015578", "ndc_label_name": "Alcohol Swabs PAD", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917012807", "ndc_label_name": "Alcohol Swabs PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917006104", "ndc_label_name": "Alcohol Swabs PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917012805", "ndc_label_name": "Alcohol Swabs PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113200078", "ndc_label_name": "Alcohol Swabs PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917003175", "ndc_label_name": "Alcohol Swabs PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917007088", "ndc_label_name": "Alcohol Swabs PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "19283059475", "ndc_label_name": "Alcohol Swabs PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917014455", "ndc_label_name": "Alcohol Swabs PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031367", "ndc_label_name": "Alcohol Swabs PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "18407061105", "ndc_label_name": "Alcohol Swabstick Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000002601", "ndc_label_name": "Alcohol Wipes 70 % External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54569610300", "ndc_label_name": "Aldara Cream 5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "99207026012", "ndc_label_name": "Aldara Cream 5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58468007001", "ndc_label_name": "Aldurazyme SOLUTION 2.9 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242013001", "ndc_label_name": "Alecensa Capsule 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51224030110", "ndc_label_name": "Alendronate Sodium Solution 70 MG/75ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115167808", "ndc_label_name": "Alendronate Sodium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079094105", "ndc_label_name": "Alendronate Sodium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115167801", "ndc_label_name": "Alendronate Sodium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862032730", "ndc_label_name": "Alendronate Sodium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093514156", "ndc_label_name": "Alendronate Sodium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505259303", "ndc_label_name": "Alendronate Sodium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980034003", "ndc_label_name": "Alendronate Sodium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093514101", "ndc_label_name": "Alendronate Sodium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079094101", "ndc_label_name": "Alendronate Sodium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111058801", "ndc_label_name": "Alendronate Sodium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378356701", "ndc_label_name": "Alendronate Sodium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714063101", "ndc_label_name": "Alendronate Sodium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071079030", "ndc_label_name": "Alendronate Sodium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980034001", "ndc_label_name": "Alendronate Sodium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505259301", "ndc_label_name": "Alendronate Sodium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714063102", "ndc_label_name": "Alendronate Sodium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111058830", "ndc_label_name": "Alendronate Sodium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261099301", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115167934", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16252059944", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093517244", "ndc_label_name": "Alendronate Sodium TABLET 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335063760", "ndc_label_name": "Alendronate Sodium TABLET 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76439013004", "ndc_label_name": "Alendronate Sodium TABLET 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115167926", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093517229", "ndc_label_name": "Alendronate Sodium TABLET 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097022376", "ndc_label_name": "Alendronate Sodium TABLET 35 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378356899", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335063768", "ndc_label_name": "Alendronate Sodium TABLET 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569604700", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16252059902", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097022316", "ndc_label_name": "Alendronate Sodium TABLET 35 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980034114", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714063201", "ndc_label_name": "Alendronate Sodium TABLET 35 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090109100", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111059048", "ndc_label_name": "Alendronate Sodium TABLET 35 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862032804", "ndc_label_name": "Alendronate Sodium TABLET 35 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714063202", "ndc_label_name": "Alendronate Sodium TABLET 35 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429005572", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429005574", "ndc_label_name": "Alendronate Sodium TABLET 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217032101", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071157704", "ndc_label_name": "Alendronate Sodium TABLET 35 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746024202", "ndc_label_name": "Alendronate Sodium TABLET 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543013004", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543013012", "ndc_label_name": "Alendronate Sodium Tablet 35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093514056", "ndc_label_name": "Alendronate Sodium Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111058930", "ndc_label_name": "Alendronate Sodium Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115167601", "ndc_label_name": "Alendronate Sodium Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111058901", "ndc_label_name": "Alendronate Sodium Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115167608", "ndc_label_name": "Alendronate Sodium Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093514001", "ndc_label_name": "Alendronate Sodium Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505259203", "ndc_label_name": "Alendronate Sodium TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378356601", "ndc_label_name": "Alendronate Sodium Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505259201", "ndc_label_name": "Alendronate Sodium TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071079130", "ndc_label_name": "Alendronate Sodium Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115168126", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714063302", "ndc_label_name": "Alendronate Sodium TABLET 70 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16252060144", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16252060102", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714063301", "ndc_label_name": "Alendronate Sodium TABLET 70 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093517129", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378356999", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093517144", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919068904", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261055401", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079094205", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335063860", "ndc_label_name": "Alendronate Sodium TABLET 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090312600", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115168134", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335063868", "ndc_label_name": "Alendronate Sodium TABLET 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356059404", "ndc_label_name": "Alendronate Sodium TABLET 70 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079094201", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090232201", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862032904", "ndc_label_name": "Alendronate Sodium TABLET 70 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090232200", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980034214", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429005672", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429005674", "ndc_label_name": "Alendronate Sodium TABLET 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788739301", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788713004", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090258701", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205004804", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090258700", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543013120", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569605000", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788739304", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505259602", "ndc_label_name": "Alendronate Sodium TABLET 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569605001", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543013104", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097022476", "ndc_label_name": "Alendronate Sodium TABLET 70 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69543013112", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111059248", "ndc_label_name": "Alendronate Sodium TABLET 70 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746024402", "ndc_label_name": "Alendronate Sodium TABLET 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788739303", "ndc_label_name": "Alendronate Sodium Tablet 70 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097022416", "ndc_label_name": "Alendronate Sodium TABLET 70 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29978091860", "ndc_label_name": "Alevazol OINTMENT 1 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "25866059361", "ndc_label_name": "Aleve Arthritis Pain Gel 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "13668002105", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440500090", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440500001", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440500005", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335095688", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378500577", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440500030", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237011490", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353094530", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353074630", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353094516", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440500081", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505285001", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300015501", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440500060", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097084407", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919034930", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353094560", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335095681", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668002101", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282030201", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300015519", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261099430", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282030205", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282030290", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097084412", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291011001", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353074660", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291011010", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862024901", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335095618", "ndc_label_name": "Alfuzosin HCl ER Tablet Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00002764001", "ndc_label_name": "Alimta Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00002762301", "ndc_label_name": "Alimta Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "27437010601", "ndc_label_name": "Alinia Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67546021221", "ndc_label_name": "Alinia Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419038501", "ndc_label_name": "Aliqopa Solution Reconstituted 60 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884042411", "ndc_label_name": "Aliskiren Fumarate Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993014130", "ndc_label_name": "Aliskiren Fumarate Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884042511", "ndc_label_name": "Aliskiren Fumarate Tablet 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993014230", "ndc_label_name": "Aliskiren Fumarate Tablet 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33674015692", "ndc_label_name": "Alive Ultra Potency Womens 50+ Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33674015903", "ndc_label_name": "Alive Womens Gummy Tablet Chewable Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52609300100", "ndc_label_name": "Alkeran Solution Reconstituted 50 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71863010950", "ndc_label_name": "Alkindi Sprinkle Capsule Sprinkle 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71863011050", "ndc_label_name": "Alkindi Sprinkle Capsule Sprinkle 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71863011150", "ndc_label_name": "Alkindi Sprinkle Capsule Sprinkle 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71863011250", "ndc_label_name": "Alkindi Sprinkle Capsule Sprinkle 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00113097426", "ndc_label_name": "All Day Allergy Childrens Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41520031860", "ndc_label_name": "All Day Allergy Childrens Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "30142097426", "ndc_label_name": "All Day Allergy Childrens Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904637220", "ndc_label_name": "All Day Allergy Childrens Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800018926", "ndc_label_name": "All Day Allergy Childrens SOLUTION 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205085526", "ndc_label_name": "All Day Allergy Childrens SOLUTION 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000018601", "ndc_label_name": "All Day Allergy Childrens Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800097426", "ndc_label_name": "All Day Allergy Childrens SOLUTION 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000021501", "ndc_label_name": "All Day Allergy Childrens SOLUTION 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000021401", "ndc_label_name": "All Day Allergy Childrens SOLUTION 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "30142045872", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904585260", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "49614022965", "ndc_label_name": "All Day Allergy TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904585243", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142045895", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142045876", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904585241", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904585289", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800045839", "ndc_label_name": "All Day Allergy TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800045887", "ndc_label_name": "All Day Allergy TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "49781010630", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904585246", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000014803", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800045866", "ndc_label_name": "All Day Allergy TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800045813", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142045839", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205082075", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800045895", "ndc_label_name": "All Day Allergy TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000038004", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904585272", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000014804", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031859", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800045872", "ndc_label_name": "All Day Allergy TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800045847", "ndc_label_name": "All Day Allergy TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205082076", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031857", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205082070", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142045813", "ndc_label_name": "All Day Allergy TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000038003", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "49614022966", "ndc_label_name": "All Day Allergy TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205082074", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031858", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000038001", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142045866", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000038002", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031898", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000014801", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000014802", "ndc_label_name": "All Day Allergy Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113217653", "ndc_label_name": "All Day Allergy-D Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113217662", "ndc_label_name": "All Day Allergy-D Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142017653", "ndc_label_name": "All Day Allergy-D Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113017653", "ndc_label_name": "All Day Allergy-D Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113017662", "ndc_label_name": "All Day Allergy-D Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904583112", "ndc_label_name": "All Day Allergy-D Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142017662", "ndc_label_name": "All Day Allergy-D Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031863", "ndc_label_name": "All Day Allergy-D Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363036878", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363090182", "ndc_label_name": "All Day Pain Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363014082", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363036862", "ndc_label_name": "All Day Pain Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800049062", "ndc_label_name": "All Day Pain Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363036837", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363036861", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363036882", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363036879", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800014082", "ndc_label_name": "All Day Pain Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363036871", "ndc_label_name": "All Day Pain Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363049078", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800049078", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363036852", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800036882", "ndc_label_name": "All Day Pain Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800036878", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363049071", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800036862", "ndc_label_name": "All Day Pain Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363049062", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800036871", "ndc_label_name": "All Day Pain Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000017101", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917008621", "ndc_label_name": "All Day Pain Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50436660601", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "49781014550", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917008896", "ndc_label_name": "All Day Pain Relief TABLET 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800049071", "ndc_label_name": "All Day Pain Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "49781014551", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000017104", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000020101", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "49781014152", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000017102", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000020103", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000020104", "ndc_label_name": "All Day Pain Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000017103", "ndc_label_name": "All Day Pain Relief TABLET 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000020102", "ndc_label_name": "All Day Pain Relief TABLET 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536109306", "ndc_label_name": "All Day Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142036878", "ndc_label_name": "All Day Relief TABLET 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536109401", "ndc_label_name": "All Day Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142036871", "ndc_label_name": "All Day Relief TABLET 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142036862", "ndc_label_name": "All Day Relief TABLET 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536109301", "ndc_label_name": "All Day Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536109406", "ndc_label_name": "All Day Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55700033530", "ndc_label_name": "All Day Relief Tablet 220 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55700013850", "ndc_label_name": "All Day Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142014082", "ndc_label_name": "All Day Relief TABLET 220 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536100601", "ndc_label_name": "Aller-Chlor Tablet 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536100635", "ndc_label_name": "Aller-Chlor Tablet 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536100610", "ndc_label_name": "Aller-Chlor TABLET 4 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41250042553", "ndc_label_name": "Aller-Ease TABLET 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113042553", "ndc_label_name": "Aller-Ease Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41250037926", "ndc_label_name": "Allergy Childrens Liquid 12.5 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41250037934", "ndc_label_name": "Allergy Childrens Liquid 12.5 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "71399012506", "ndc_label_name": "Allergy Childrens Liquid 12.5 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "71399012508", "ndc_label_name": "Allergy Childrens Liquid 12.5 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63868082354", "ndc_label_name": "Allergy Childrens Liquid 12.5 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "75450029539", "ndc_label_name": "Allergy Childrens Liquid 12.5 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "71399012504", "ndc_label_name": "Allergy Childrens Liquid 12.5 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800013108", "ndc_label_name": "Allergy Childrens Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000012501", "ndc_label_name": "Allergy Childrens Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000025201", "ndc_label_name": "Allergy Childrens Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61269052798", "ndc_label_name": "Allergy Childrens Suspension 30 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61269052794", "ndc_label_name": "Allergy Childrens Suspension 30 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000063502", "ndc_label_name": "Allergy Nasal Spray Suspension 50 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917012397", "ndc_label_name": "Allergy Nasal Spray Suspension 50 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230030340", "ndc_label_name": "Allergy Relief (Cetirizine) Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230030324", "ndc_label_name": "Allergy Relief (Cetirizine) Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "13874002003", "ndc_label_name": "Allergy Relief (Loratadine) Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51824007501", "ndc_label_name": "Allergy Relief (Loratadine) Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917020205", "ndc_label_name": "Allergy Relief (Loratadine) Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000058301", "ndc_label_name": "Allergy Relief (Loratadine) Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230032803", "ndc_label_name": "Allergy Relief (Loratadine) Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230032801", "ndc_label_name": "Allergy Relief (Loratadine) Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230030324", "ndc_label_name": "Allergy Relief Capsule 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000020702", "ndc_label_name": "Allergy Relief Capsule 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113046262", "ndc_label_name": "Allergy Relief Capsule 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000020701", "ndc_label_name": "Allergy Relief Capsule 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000014401", "ndc_label_name": "Allergy Relief Capsule 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58602044509", "ndc_label_name": "Allergy Relief Cetirizine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "49483068201", "ndc_label_name": "Allergy Relief Cetirizine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230031611", "ndc_label_name": "Allergy Relief Childrens Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000039201", "ndc_label_name": "Allergy Relief D Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000050403", "ndc_label_name": "Allergy Relief D-12 Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000050401", "ndc_label_name": "Allergy Relief D-12 Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000050402", "ndc_label_name": "Allergy Relief D-12 Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205034888", "ndc_label_name": "Allergy Relief D-24 Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "49614017252", "ndc_label_name": "Allergy Relief D-24 Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000016201", "ndc_label_name": "Allergy Relief D-24 Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205034852", "ndc_label_name": "Allergy Relief D-24 Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000016202", "ndc_label_name": "Allergy Relief D-24 Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000011001", "ndc_label_name": "Allergy Relief SUSPENSION 50 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113061246", "ndc_label_name": "Allergy Relief TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113061265", "ndc_label_name": "Allergy Relief TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904569915", "ndc_label_name": "Allergy Relief TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142061272", "ndc_label_name": "Allergy Relief TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113061239", "ndc_label_name": "Allergy Relief TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660052611", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113061260", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142061265", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142061276", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031069", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142061246", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800061276", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660052653", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000021305", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800061265", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800061287", "ndc_label_name": "Allergy Relief TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800061246", "ndc_label_name": "Allergy Relief TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660052631", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031474", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000031701", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000021304", "ndc_label_name": "Allergy Relief TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230031201", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031334", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031473", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031068", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660052605", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660052601", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000021303", "ndc_label_name": "Allergy Relief TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031404", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230031203", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660052630", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660052660", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230031230", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000021301", "ndc_label_name": "Allergy Relief TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000021302", "ndc_label_name": "Allergy Relief Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55700050030", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230030030", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55700050090", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000021202", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55700050060", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230020201", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230020230", "ndc_label_name": "Allergy Relief TABLET 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71335050601", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000021203", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230030001", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230030005", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000021201", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000021204", "ndc_label_name": "Allergy Relief Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113047962", "ndc_label_name": "Allergy Relief TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000013601", "ndc_label_name": "Allergy Relief Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113047953", "ndc_label_name": "Allergy Relief Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000013602", "ndc_label_name": "Allergy Relief TABLET 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113047978", "ndc_label_name": "Allergy Relief TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000013603", "ndc_label_name": "Allergy Relief TABLET 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000016002", "ndc_label_name": "Allergy Relief TABLET 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000016001", "ndc_label_name": "Allergy Relief Tablet 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113004278", "ndc_label_name": "Allergy Relief Tablet 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000036201", "ndc_label_name": "Allergy Relief Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000036202", "ndc_label_name": "Allergy Relief Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800053852", "ndc_label_name": "Allergy Relief-D Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41250023979", "ndc_label_name": "Allergy Relief-D Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "52544023912", "ndc_label_name": "Allergy Relief-D Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "52544023954", "ndc_label_name": "Allergy Relief-D Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41250023912", "ndc_label_name": "Allergy Relief-D Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230030405", "ndc_label_name": "Allergy Relief/Indoor/Outdoor Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230030401", "ndc_label_name": "Allergy Relief/Indoor/Outdoor Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69230030430", "ndc_label_name": "Allergy Relief/Indoor/Outdoor Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660094024", "ndc_label_name": "Allergy Relief/Nasal Decongest Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660072456", "ndc_label_name": "Allergy Relief/Nasal Decongest Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660072469", "ndc_label_name": "Allergy Relief/Nasal Decongest Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41250072452", "ndc_label_name": "Allergy Relief/Nasal Decongest Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660072401", "ndc_label_name": "Allergy Relief/Nasal Decongest Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660072415", "ndc_label_name": "Allergy Relief/Nasal Decongest Tablet Extended Release 24 Hour 10-240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800046362", "ndc_label_name": "Allergy TABLET 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904001224", "ndc_label_name": "Allergy Tablet 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904001259", "ndc_label_name": "Allergy TABLET 4 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904001280", "ndc_label_name": "Allergy TABLET 4 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205021578", "ndc_label_name": "Allergy TABLET 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904001261", "ndc_label_name": "Allergy Tablet 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483024201", "ndc_label_name": "Allergy-Time Tablet 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483024210", "ndc_label_name": "Allergy-Time Tablet 4 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113200760", "ndc_label_name": "Allergy/Congestion Relief Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113201339", "ndc_label_name": "Allergy/Congestion Relief Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113201352", "ndc_label_name": "Allergy/Congestion Relief Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00113201360", "ndc_label_name": "Allergy/Congestion Relief Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00591554301", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705030", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004107", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705085", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356085690", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904657161", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378013710", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378013701", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591554310", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211593", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261081060", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211521", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063097590", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004110", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705081", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705091", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261081000", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300034901", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063079390", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211532", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742013501", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729013416", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705090", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729013401", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063007920", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300034910", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063097520", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300034905", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569023304", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261081090", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004112", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356085660", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063007930", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261081030", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006311", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356085630", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018001", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111072910", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063007960", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063007990", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063079360", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001200", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075460", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090254403", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62584098811", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167504", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063093501", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489015610", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090254404", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063079320", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073680", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569023303", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075401", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739041010", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999037490", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018018", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742013510", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999037430", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544098880", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919074830", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267066530", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075430", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020520", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018090", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020501", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006315", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788738301", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167502", "ndc_label_name": "Allopurinol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788983209", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243030509", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489015601", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62584098801", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489015605", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959047300", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788983203", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544098860", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111072901", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267066560", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760011430", "ndc_label_name": "Allopurinol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167501", "ndc_label_name": "Allopurinol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118211503", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959047330", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710120900", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788738303", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304053910", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073660", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760011490", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075412", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075420", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868007501", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610019760", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788738309", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544098830", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788211509", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760013490", "ndc_label_name": "Allopurinol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073630", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788211503", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018010", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919074890", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335046701", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710120901", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075414", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304053901", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205020830", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934007230", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243011509", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167503", "ndc_label_name": "Allopurinol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335046702", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205020890", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610019460", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075440", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610019480", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335046703", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243030518", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335046704", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267066590", "ndc_label_name": "Allopurinol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610019780", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073674", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335046705", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335046706", "ndc_label_name": "Allopurinol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69315040909", "ndc_label_name": "Allopurinol Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571088409", "ndc_label_name": "Allopurinol Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705190", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378018105", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211621", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705160", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090186703", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378018101", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705130", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705185", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591554401", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591554405", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004210", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261059760", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742013601", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705181", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440705191", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211602", "ndc_label_name": "Allopurinol TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742013605", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211628", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729013516", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261059799", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959031100", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603211632", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300035001", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904657261", "ndc_label_name": "Allopurinol TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020601", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261059790", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261059730", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063077430", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489015701", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904261460", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300035010", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090186700", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489015705", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063077490", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353018660", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436302803", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075501", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714004211", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358001360", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020617", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569023503", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999024503", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020619", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489015710", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335011202", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729013501", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063093401", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001001", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001090", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006411", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959031160", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569023501", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335059903", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300035005", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063097690", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700003530", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118211608", "ndc_label_name": "Allopurinol TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700054030", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569023500", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111073001", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760011890", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063097630", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353008860", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700054090", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919047190", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919047130", "ndc_label_name": "Allopurinol TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111073005", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001003", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544037160", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959031130", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090186701", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018101", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788632303", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075514", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001030", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018190", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788642201", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62584071301", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006415", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075530", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335011203", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075540", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429018105", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760011830", "ndc_label_name": "Allopurinol TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335059902", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629178101", "ndc_label_name": "Allopurinol TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079020620", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267022460", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760013990", "ndc_label_name": "Allopurinol TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544037130", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700003590", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62584071311", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304054001", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739079610", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629178103", "ndc_label_name": "Allopurinol TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788642203", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267022430", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710121001", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075510", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304054005", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788060303", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075520", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075590", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788983103", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610023160", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335011201", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243035509", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629178102", "ndc_label_name": "Allopurinol TABLET 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267022490", "ndc_label_name": "Allopurinol TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075550", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335011204", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205004930", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335059904", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544031360", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610006460", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874075512", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335059901", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116047130", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610025360", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788632301", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710121005", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205037790", "ndc_label_name": "Allopurinol Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70362072230", "ndc_label_name": "Allzital Tablet 25-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70569015001", "ndc_label_name": "Allzital Tablet 25-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70362072201", "ndc_label_name": "Allzital Tablet 25-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70569015030", "ndc_label_name": "Allzital Tablet 25-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00536001583", "ndc_label_name": "Almacone Double Strength SUSPENSION 400-400-40 MG/5ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00093526119", "ndc_label_name": "Almotriptan Malate Tablet 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10147096101", "ndc_label_name": "Almotriptan Malate Tablet 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093526129", "ndc_label_name": "Almotriptan Malate Tablet 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378524685", "ndc_label_name": "Almotriptan Malate TABLET 12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378524632", "ndc_label_name": "Almotriptan Malate Tablet 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241004268", "ndc_label_name": "Almotriptan Malate TABLET 12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241004221", "ndc_label_name": "Almotriptan Malate TABLET 12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378524585", "ndc_label_name": "Almotriptan Malate TABLET 6.25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241004168", "ndc_label_name": "Almotriptan Malate TABLET 6.25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378524532", "ndc_label_name": "Almotriptan Malate Tablet 6.25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093526018", "ndc_label_name": "Almotriptan Malate Tablet 6.25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241004111", "ndc_label_name": "Almotriptan Malate TABLET 6.25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093526019", "ndc_label_name": "Almotriptan Malate Tablet 6.25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10147096201", "ndc_label_name": "Almotriptan Malate Tablet 6.25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00023884205", "ndc_label_name": "Alocril SOLUTION 2 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802010365", "ndc_label_name": "Alogliptin Benzoate Tablet 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802015065", "ndc_label_name": "Alogliptin Benzoate Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610030009", "ndc_label_name": "Alogliptin Benzoate Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802008765", "ndc_label_name": "Alogliptin Benzoate Tablet 6.25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802021172", "ndc_label_name": "Alogliptin-metFORMIN HCl Tablet 12.5-1000 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802016972", "ndc_label_name": "Alogliptin-metFORMIN HCl Tablet 12.5-500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802023865", "ndc_label_name": "Alogliptin-Pioglitazone Tablet 12.5-15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802026065", "ndc_label_name": "Alogliptin-Pioglitazone Tablet 12.5-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802030465", "ndc_label_name": "Alogliptin-Pioglitazone Tablet 12.5-45 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802035165", "ndc_label_name": "Alogliptin-Pioglitazone Tablet 25-15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802040265", "ndc_label_name": "Alogliptin-Pioglitazone Tablet 25-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802049965", "ndc_label_name": "Alogliptin-Pioglitazone Tablet 25-45 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00065034510", "ndc_label_name": "Alomide Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023588512", "ndc_label_name": "Alora Patch Twice Weekly 0.025 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544088454", "ndc_label_name": "Alora Patch Twice Weekly 0.025 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544088408", "ndc_label_name": "Alora Patch Twice Weekly 0.025 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023588502", "ndc_label_name": "Alora Patch Twice Weekly 0.025 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023588615", "ndc_label_name": "Alora Patch Twice Weekly 0.05 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023588605", "ndc_label_name": "Alora Patch Twice Weekly 0.05 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544047108", "ndc_label_name": "Alora Patch Twice Weekly 0.05 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544047154", "ndc_label_name": "Alora Patch Twice Weekly 0.05 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023588707", "ndc_label_name": "Alora Patch Twice Weekly 0.075 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023588717", "ndc_label_name": "Alora Patch Twice Weekly 0.075 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544047254", "ndc_label_name": "Alora Patch Twice Weekly 0.075 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544047208", "ndc_label_name": "Alora Patch Twice Weekly 0.075 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544047308", "ndc_label_name": "Alora Patch Twice Weekly 0.1 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023588801", "ndc_label_name": "Alora Patch Twice Weekly 0.1 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544047354", "ndc_label_name": "Alora Patch Twice Weekly 0.1 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023588811", "ndc_label_name": "Alora Patch Twice Weekly 0.1 MG/24HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45963047903", "ndc_label_name": "Alosetron HCl Tablet 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884081911", "ndc_label_name": "Alosetron HCl Tablet 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162024803", "ndc_label_name": "Alosetron HCl TABLET 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980045303", "ndc_label_name": "Alosetron HCl Tablet 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054029513", "ndc_label_name": "Alosetron HCl Tablet 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291012330", "ndc_label_name": "Alosetron HCl Tablet 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054029613", "ndc_label_name": "Alosetron HCl Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291012430", "ndc_label_name": "Alosetron HCl Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884082011", "ndc_label_name": "Alosetron HCl Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45963048003", "ndc_label_name": "Alosetron HCl Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162024903", "ndc_label_name": "Alosetron HCl TABLET 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980045403", "ndc_label_name": "Alosetron HCl Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11694088604", "ndc_label_name": "Alph-E-Mixed 1000 Capsule 1000 UNIT Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11694092401", "ndc_label_name": "Alph-E-Mixed Capsule 200 UNIT Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00023932105", "ndc_label_name": "Alphagan P Solution 0.1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023932110", "ndc_label_name": "Alphagan P Solution 0.1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023932115", "ndc_label_name": "Alphagan P Solution 0.1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569633200", "ndc_label_name": "Alphagan P Solution 0.1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023917705", "ndc_label_name": "Alphagan P SOLUTION 0.15 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023917710", "ndc_label_name": "Alphagan P SOLUTION 0.15 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023917715", "ndc_label_name": "Alphagan P SOLUTION 0.15 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460702", "ndc_label_name": "Alphanate Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516461302", "ndc_label_name": "Alphanate Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460802", "ndc_label_name": "Alphanate Solution Reconstituted 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516461402", "ndc_label_name": "Alphanate Solution Reconstituted 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516461502", "ndc_label_name": "Alphanate Solution Reconstituted 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516461002", "ndc_label_name": "Alphanate Solution Reconstituted 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460501", "ndc_label_name": "Alphanate Solution Reconstituted 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516461101", "ndc_label_name": "Alphanate Solution Reconstituted 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460601", "ndc_label_name": "Alphanate Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516461201", "ndc_label_name": "Alphanate Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460302", "ndc_label_name": "Alphanate/VWF Complex/Human Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460402", "ndc_label_name": "Alphanate/VWF Complex/Human Solution Reconstituted 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460902", "ndc_label_name": "Alphanate/VWF Complex/Human Solution Reconstituted 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460101", "ndc_label_name": "Alphanate/VWF Complex/Human Solution Reconstituted 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516460201", "ndc_label_name": "Alphanate/VWF Complex/Human Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360202", "ndc_label_name": "AlphaNine SD Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360502", "ndc_label_name": "AlphaNine SD Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360802", "ndc_label_name": "AlphaNine SD Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360302", "ndc_label_name": "AlphaNine SD Solution Reconstituted 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360602", "ndc_label_name": "AlphaNine SD Solution Reconstituted 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360902", "ndc_label_name": "AlphaNine SD Solution Reconstituted 1500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360102", "ndc_label_name": "AlphaNine SD Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360702", "ndc_label_name": "AlphaNine SD Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68516360402", "ndc_label_name": "AlphaNine SD Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629406101", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228308306", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862045460", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093545006", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629406102", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959096430", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093545106", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261074100", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959096560", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261074121", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189002990", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335042702", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261074145", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261074160", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228308406", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261074142", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629536401", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261074190", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261074130", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862045560", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569618700", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959096515", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629536402", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189002960", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788694303", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959096530", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788694306", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629536403", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788694309", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335042701", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189002930", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228308706", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862045660", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093545206", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862045760", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 3 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228308606", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 3 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093545306", "ndc_label_name": "ALPRAZolam ER Tablet Extended Release 24 Hour 3 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054306844", "ndc_label_name": "ALPRAZolam Intensol CONCENTRATE 1 MG/ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707006", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707060", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202796", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202710", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707090", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544005430", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781106110", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544015560", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707030", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544002930", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544010430", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202750", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261059460", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261059430", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544015590", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261059420", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781106101", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544015530", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037020", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378400105", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037030", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261059490", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063008806", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001460", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037060", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037005", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035753", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781106105", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035760", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001430", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037090", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037098", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060318", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035715", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060388", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904585861", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003930", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070530", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070560", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035730", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070405", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070553", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463401", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060313", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032100", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463402", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003960", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035770", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096260", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079078820", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096298", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090225604", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032114", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079078801", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090225600", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070515", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700042260", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070410", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919044730", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070401", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032190", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375501", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032110", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070570", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700042290", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032102", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739064410", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032120", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375500", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050230", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032160", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090225601", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700067130", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375502", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025101", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959032130", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375505", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919037930", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762371901", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375504", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700067160", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700042230", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025114", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868292904", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096205", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187091630", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025112", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096220", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000580", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025120", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025115", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096290", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919044760", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295501", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025174", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096230", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012460", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025172", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063001", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025102", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295503", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295502", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267021990", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762371903", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073453", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025177", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090011", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267021960", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295505", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295504", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090050", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762371904", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084064701", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025190", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012470", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090009", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295506", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862067699", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041430", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295507", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788202709", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041445", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073470", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000560", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063010", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000530", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073430", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025110", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788635802", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041470", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788202703", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041415", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267021930", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000553", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686502", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025130", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788900103", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073415", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788635803", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041460", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041453", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000570", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686509", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025160", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011270", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788635809", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686506", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073480", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073445", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012415", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016301", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063005", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084064711", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686503", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011020", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788635806", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788900109", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012445", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016304", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66116023230", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011032", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788995403", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016308", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016309", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205029030", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788995409", "ndc_label_name": "ALPRAZolam TABLET 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335081301", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090010", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016303", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016305", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011230", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000515", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016306", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016307", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011260", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000545", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011253", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012430", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544012453", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041480", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544073460", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011030", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016302", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72789004230", "ndc_label_name": "ALPRAZolam Tablet 0.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378400305", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202950", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707130", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707110", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000420", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000421", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107705", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202910", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707190", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228202996", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904585961", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107710", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036706", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001560", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000428", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707160", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107701", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707103", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000410", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063006106", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036715", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035860", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036730", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707191", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000402", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707106", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000460", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036798", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036790", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035880", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035853", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000430", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055545", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000407", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001530", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035870", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035892", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055530", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055520", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000440", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055575", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000414", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001590", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079078901", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055580", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055560", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055570", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000490", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003290", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001540", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036760", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079078920", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060418", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055592", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045742", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001520", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463501", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035820", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035845", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045700", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003200", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060413", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045745", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035830", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070505", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035875", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003260", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002039505", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003230", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045715", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375602", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055515", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045760", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055555", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070510", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372003", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463502", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045720", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868293006", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055553", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002039515", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003215", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045728", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919084930", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070501", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045730", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094560", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353055590", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002039530", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090175900", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002039510", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154106", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375601", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094598", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919000530", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090175901", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094506", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090175902", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372004", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025220", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375604", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031360", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154103", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045790", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031330", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045702", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919045630", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090110", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868293008", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050330", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629772602", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375600", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372001", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002039520", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025210", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041592", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919000560", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919084960", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629772607", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569375603", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050318", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031390", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001330", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041915", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025206", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154104", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025230", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094515", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919000590", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050345", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041515", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062953", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025214", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629772600", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025260", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094530", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154107", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154101", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041930", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084067201", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025272", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629772601", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025274", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289094590", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629772606", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629772604", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062992", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335024704", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025290", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739066910", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025277", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154102", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025202", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629772605", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788900209", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335024709", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862067799", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025204", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000630", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629154105", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025212", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025250", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788995303", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335076105", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000615", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025209", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000660", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629772603", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063101", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063105", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788995306", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335092902", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000645", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025215", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000675", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629772608", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041545", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090111", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011132", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335092908", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000670", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025218", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062980", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629772609", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041560", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041553", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335024708", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335092909", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041580", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001360", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788202906", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025201", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041570", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041975", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335092907", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025224", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041920", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001390", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788900203", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063110", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041960", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041980", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335109202", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090150", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041945", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000680", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011120", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000620", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041970", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062955", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025203", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000653", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062915", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041520", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025205", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041575", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062975", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025200", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025208", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041953", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062920", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544041530", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335085002", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071201509", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025201", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335076102", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335109205", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788995309", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062945", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062930", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025204", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205028430", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062960", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335092900", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335076106", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335024703", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788202903", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062970", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335092906", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025202", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335024701", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335092901", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335024702", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025207", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335024707", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544062990", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025206", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335025209", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335084905", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335092903", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335109206", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335084906", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084067211", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335092904", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72789002490", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335092905", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788900206", "ndc_label_name": "ALPRAZolam TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011130", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335024700", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335024705", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335024706", "ndc_label_name": "ALPRAZolam Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228203150", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228203196", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228203110", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544010630", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707291", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107910", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000506", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707230", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904586061", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107905", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378400505", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000590", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000530", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000500", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356074490", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781107901", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063060930", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001600", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707290", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001630", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001610", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000502", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035960", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000515", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035970", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001660", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055630", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001640", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001620", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356074430", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035980", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000560", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035975", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055690", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063060960", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356074410", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036430", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356074460", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035990", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036498", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057253", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035945", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035930", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036440", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063060940", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036406", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090289601", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063060990", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057260", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057270", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090242501", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055606", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353035953", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036460", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569461902", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060588", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057275", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060513", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070601", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055660", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057230", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036490", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700049130", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079079001", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092006", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052400", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052414", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055698", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057290", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055640", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118060509", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569461906", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050415", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052410", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052430", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090242503", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463601", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057215", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025350", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868300506", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050418", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052490", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569461900", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079079020", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463602", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057280", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000745", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092040", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919083690", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372103", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092060", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052402", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070605", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463603", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000753", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031290", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025320", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760055030", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700049190", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052428", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569461903", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070610", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029090", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919008930", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025373", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919000660", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294206", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052460", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868300500", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052406", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034730", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919008960", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090250", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919083630", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294209", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569461901", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092098", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919063960", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034753", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294203", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034745", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294208", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025303", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092030", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760081330", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919083660", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042015", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025360", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034780", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000730", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025318", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092090", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919000630", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294201", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638103", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034790", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638101", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000755", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025325", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700049160", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187044330", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294204", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788900309", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788995209", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335009802", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029045", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025328", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372101", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294202", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025301", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011232", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011230", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021502", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034760", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025372", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372104", "ndc_label_name": "ALPRAZolam TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294205", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025304", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335009803", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205022730", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021505", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042080", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090211", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294200", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025312", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025310", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335009804", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335009805", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068004", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638102", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029075", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629294207", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025314", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063205", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335009806", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335009807", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025340", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011220", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034715", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739067410", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063210", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001490", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021506", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335009808", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001460", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021501", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034755", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025315", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001491", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090210", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021509", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021500", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000775", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021504", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042055", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025321", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029015", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000770", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638106", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021507", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029055", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068003", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638109", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025324", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029080", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000780", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068006", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068001", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034770", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068008", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068007", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025330", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544034775", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000790", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042045", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011360", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042053", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029030", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042060", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025374", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042070", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029060", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042075", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025377", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638108", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029070", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335009809", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025390", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068002", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042030", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011353", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063201", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335009800", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862067899", "ndc_label_name": "ALPRAZolam TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021508", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001430", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068009", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000715", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000760", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029053", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544042090", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335009801", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021503", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068000", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068005", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011330", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011370", "ndc_label_name": "ALPRAZolam Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781108905", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261050090", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261050030", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001790", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707360", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228203910", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335060688", "ndc_label_name": "ALPRAZolam TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378400701", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544010730", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999025360", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001740", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289052360", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707390", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781108901", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463303", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063082840", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358001760", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086430", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999025390", "ndc_label_name": "ALPRAZolam TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874101602", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999025300", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261050002", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086460", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086410", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070701", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086440", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086490", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874101605", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090281901", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261050060", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569490002", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700060260", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569490001", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700062260", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868466303", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090310", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086400", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436463302", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700060230", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919086260", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330801", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919057660", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289052301", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788943009", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289052330", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991070705", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372203", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874101609", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874101603", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063305", "ndc_label_name": "ALPRAZolam TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64376063301", "ndc_label_name": "ALPRAZolam TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335067301", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289052390", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569490000", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050518", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788761302", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874101606", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335067302", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267056491", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335067304", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762372201", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289052340", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050560", "ndc_label_name": "ALPRAZolam TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011320", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788943003", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189005860", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788761303", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335067306", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874101608", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700062230", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330802", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919057690", "ndc_label_name": "ALPRAZolam TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788943006", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330803", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788943002", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788761306", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788761309", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330804", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335067305", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69452011330", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874101601", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335067303", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874101604", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862067905", "ndc_label_name": "ALPRAZolam TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67253090350", "ndc_label_name": "ALPRAZolam Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228401911", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 0.25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884011052", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 0.25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884011074", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 0.25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884011174", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 0.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228402211", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 0.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884011152", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 0.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884021352", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884021374", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228402411", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884021474", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884021452", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228402511", "ndc_label_name": "ALPRAZolam TABLET DISPERSIBLE 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762005701", "ndc_label_name": "ALPRAZolam XR Tablet Extended Release 24 Hour 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762005901", "ndc_label_name": "ALPRAZolam XR Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356050360", "ndc_label_name": "ALPRAZolam XR Tablet Extended Release 24 Hour 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762006601", "ndc_label_name": "ALPRAZolam XR Tablet Extended Release 24 Hour 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356050460", "ndc_label_name": "ALPRAZolam XR Tablet Extended Release 24 Hour 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762006801", "ndc_label_name": "ALPRAZolam XR Tablet Extended Release 24 Hour 3 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356050560", "ndc_label_name": "ALPRAZolam XR Tablet Extended Release 24 Hour 3 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64406092201", "ndc_label_name": "Alprolix Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104092201", "ndc_label_name": "Alprolix Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406093301", "ndc_label_name": "Alprolix Solution Reconstituted 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104093301", "ndc_label_name": "Alprolix Solution Reconstituted 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104096601", "ndc_label_name": "Alprolix Solution Reconstituted 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406096601", "ndc_label_name": "Alprolix Solution Reconstituted 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406094401", "ndc_label_name": "Alprolix Solution Reconstituted 3000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104094401", "ndc_label_name": "Alprolix Solution Reconstituted 3000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104097701", "ndc_label_name": "Alprolix Solution Reconstituted 4000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406097701", "ndc_label_name": "Alprolix Solution Reconstituted 4000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406091101", "ndc_label_name": "Alprolix Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104091101", "ndc_label_name": "Alprolix Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569539400", "ndc_label_name": "Alrex Suspension 0.2 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208035305", "ndc_label_name": "Alrex Suspension 0.2 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208035310", "ndc_label_name": "Alrex Suspension 0.2 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61570011001", "ndc_label_name": "Altace Capsule 1.25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569593600", "ndc_label_name": "Altace Capsule 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289086730", "ndc_label_name": "Altace Capsule 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61570012001", "ndc_label_name": "Altace CAPSULE 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864084730", "ndc_label_name": "Altace Capsule 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61570011101", "ndc_label_name": "Altace CAPSULE 2.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864067430", "ndc_label_name": "Altace Capsule 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61570011201", "ndc_label_name": "Altace Capsule 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569371400", "ndc_label_name": "Altace Capsule 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999093430", "ndc_label_name": "Altace Capsule 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70700011685", "ndc_label_name": "Altavera Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70700011684", "ndc_label_name": "Altavera Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781558315", "ndc_label_name": "Altavera Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "38415051002", "ndc_label_name": "Alternate Site Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70515062830", "ndc_label_name": "Altoprev Tablet Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59630062830", "ndc_label_name": "Altoprev Tablet Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70515062930", "ndc_label_name": "Altoprev Tablet Extended Release 24 Hour 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59630062930", "ndc_label_name": "Altoprev Tablet Extended Release 24 Hour 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70515063030", "ndc_label_name": "Altoprev Tablet Extended Release 24 Hour 60 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187000545", "ndc_label_name": "Altreno Lotion 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187000520", "ndc_label_name": "Altreno Lotion 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104098808", "ndc_label_name": "Altuviiio Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104098101", "ndc_label_name": "Altuviiio Solution Reconstituted 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104098908", "ndc_label_name": "Altuviiio Solution Reconstituted 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104098201", "ndc_label_name": "Altuviiio Solution Reconstituted 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104098508", "ndc_label_name": "Altuviiio Solution Reconstituted 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104097801", "ndc_label_name": "Altuviiio Solution Reconstituted 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104098301", "ndc_label_name": "Altuviiio Solution Reconstituted 3000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104099008", "ndc_label_name": "Altuviiio Solution Reconstituted 3000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104099108", "ndc_label_name": "Altuviiio Solution Reconstituted 4000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104098401", "ndc_label_name": "Altuviiio Solution Reconstituted 4000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104098608", "ndc_label_name": "Altuviiio Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71104097901", "ndc_label_name": "Altuviiio Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224016212", "ndc_label_name": "Alum Sulfate-Ca Acetate Packet External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536009185", "ndc_label_name": "Aluminum Hydroxide Gel SUSPENSION 320 MG/5ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63020018030", "ndc_label_name": "Alunbrig Tablet 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63020011330", "ndc_label_name": "Alunbrig Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76189011321", "ndc_label_name": "Alunbrig Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76189011318", "ndc_label_name": "Alunbrig Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63020009007", "ndc_label_name": "Alunbrig Tablet 90 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63020009030", "ndc_label_name": "Alunbrig Tablet 90 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63020019830", "ndc_label_name": "Alunbrig Tablet Therapy Pack 90 & 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00480327456", "ndc_label_name": "Alvaiz Tablet 18 MG Oral", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00480327556", "ndc_label_name": "Alvaiz Tablet 36 MG Oral", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00480327656", "ndc_label_name": "Alvaiz Tablet 54 MG Oral", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00480327356", "ndc_label_name": "Alvaiz Tablet 9 MG Oral", "drug_tier": "Tier 2", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63402071201", "ndc_label_name": "Alvesco Aerosol Solution 160 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70515071201", "ndc_label_name": "Alvesco Aerosol Solution 160 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63402071101", "ndc_label_name": "Alvesco Aerosol Solution 80 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70515071101", "ndc_label_name": "Alvesco Aerosol Solution 80 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569657300", "ndc_label_name": "Alyacen 1/35 Tablet 1-35 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090147700", "ndc_label_name": "Alyacen 1/35 Tablet 1-35 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462039429", "ndc_label_name": "Alyacen 1/35 TABLET 1-35 MG-MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462039484", "ndc_label_name": "Alyacen 1/35 TABLET 1-35 MG-MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090147800", "ndc_label_name": "Alyacen 7/7/7 Tablet 0.5/0.75/1-35 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462055629", "ndc_label_name": "Alyacen 7/7/7 TABLET 0.5/0.75/1-35 MG-MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462055684", "ndc_label_name": "Alyacen 7/7/7 TABLET 0.5/0.75/1-35 MG-MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569657400", "ndc_label_name": "Alyacen 7/7/7 Tablet 0.5/0.75/1-35 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093333406", "ndc_label_name": "Alyq Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180082911", "ndc_label_name": "Amabelz Tablet 0.5-0.1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180082913", "ndc_label_name": "Amabelz Tablet 0.5-0.1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180083013", "ndc_label_name": "Amabelz Tablet 1-0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180083011", "ndc_label_name": "Amabelz Tablet 1-0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440707520", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440707504", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440707510", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832201200", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440707506", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527170401", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781204801", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591493001", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527170405", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781204805", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832201250", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155036201", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261077390", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591493005", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904663006", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261077360", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10888500603", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001214", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904663061", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261077310", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006915", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832101500", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353085318", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42543049305", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42543049301", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687042211", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155036205", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261077330", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000710", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832101550", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629268102", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999032414", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001220", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332024671", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261077300", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291012550", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000715", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864079510", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001520", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000730", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205022320", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629268103", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261077314", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353094705", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569008402", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382051205", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788697503", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569008403", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001210", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788697502", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999032420", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332024631", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268006911", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788697501", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079024720", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687042201", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000714", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788697504", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000720", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097092607", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000760", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452014220", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001514", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629268101", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382051201", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452014230", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629268104", "ndc_label_name": "Amantadine HCl CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084061101", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084061111", "ndc_label_name": "Amantadine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383080710", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "39328053099", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687079742", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569563500", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383080712", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "39328053010", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121064610", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121064616", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135001047", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432009316", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687079756", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687023942", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "39328053016", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383080716", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135001159", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687023956", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135001124", "ndc_label_name": "Amantadine HCl Solution 50 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832011103", "ndc_label_name": "Amantadine HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591492001", "ndc_label_name": "Amantadine HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42543049705", "ndc_label_name": "Amantadine HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832011100", "ndc_label_name": "Amantadine HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832011189", "ndc_label_name": "Amantadine HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591492005", "ndc_label_name": "Amantadine HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42543049701", "ndc_label_name": "Amantadine HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59746069901", "ndc_label_name": "Amantadine HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097092512", "ndc_label_name": "Amantadine HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832011150", "ndc_label_name": "Amantadine HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097092507", "ndc_label_name": "Amantadine HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00039022110", "ndc_label_name": "Amaryl Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00039022210", "ndc_label_name": "Amaryl Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00039022310", "ndc_label_name": "Amaryl Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289020530", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629314102", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629459701", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353044330", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629314105", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024552131", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629314104", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959087030", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629314103", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629314106", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071036130", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629314101", "ndc_label_name": "Ambien CR Tablet Extended Release 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289057230", "ndc_label_name": "Ambien CR Tablet Extended Release 6.25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024550131", "ndc_label_name": "Ambien CR Tablet Extended Release 6.25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024542131", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036315", "ndc_label_name": "Ambien Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036320", "ndc_label_name": "Ambien Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003710", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003700", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289079220", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036330", "ndc_label_name": "Ambien Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036321", "ndc_label_name": "Ambien Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001612", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001620", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036325", "ndc_label_name": "Ambien Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003715", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999003720", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036310", "ndc_label_name": "Ambien Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289079212", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036360", "ndc_label_name": "Ambien Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289079206", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289079210", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001610", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289079230", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001630", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001628", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001660", "ndc_label_name": "Ambien TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874092408", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036260", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036210", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289072912", "ndc_label_name": "Ambien TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999045330", "ndc_label_name": "Ambien TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024540131", "ndc_label_name": "Ambien TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999045315", "ndc_label_name": "Ambien TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874092406", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001710", "ndc_label_name": "Ambien TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289072906", "ndc_label_name": "Ambien TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036220", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000914", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036230", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569382703", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959036215", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874092430", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267001730", "ndc_label_name": "Ambien TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874092460", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874092440", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000907", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874092401", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289072930", "ndc_label_name": "Ambien TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874092410", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000953", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000915", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864089106", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000920", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874092420", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000930", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874092490", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544000931", "ndc_label_name": "Ambien Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70710118003", "ndc_label_name": "Ambrisentan Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378427193", "ndc_label_name": "Ambrisentan Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42794005208", "ndc_label_name": "Ambrisentan Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884035462", "ndc_label_name": "Ambrisentan Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335023783", "ndc_label_name": "Ambrisentan Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884035411", "ndc_label_name": "Ambrisentan Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591240630", "ndc_label_name": "Ambrisentan Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097038702", "ndc_label_name": "Ambrisentan Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70710117903", "ndc_label_name": "Ambrisentan Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097038602", "ndc_label_name": "Ambrisentan Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378427093", "ndc_label_name": "Ambrisentan Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335023683", "ndc_label_name": "Ambrisentan Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591240530", "ndc_label_name": "Ambrisentan Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884035311", "ndc_label_name": "Ambrisentan Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42794005108", "ndc_label_name": "Ambrisentan Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884035362", "ndc_label_name": "Ambrisentan Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00168027830", "ndc_label_name": "Amcinonide Cream 0.1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168027860", "ndc_label_name": "Amcinonide Cream 0.1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168027815", "ndc_label_name": "Amcinonide Cream 0.1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168028060", "ndc_label_name": "Amcinonide Lotion 0.1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "73308040760", "ndc_label_name": "Amcinonide Ointment 0.1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168027960", "ndc_label_name": "Amcinonide Ointment 0.1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00173056100", "ndc_label_name": "Amerge Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173056200", "ndc_label_name": "Amerge Tablet 2.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862004701", "ndc_label_name": "Amethia Tablet 0.15-0.03 &0.01 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862004791", "ndc_label_name": "Amethia Tablet 0.15-0.03 &0.01 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544029531", "ndc_label_name": "Amethyst TABLET 90-20 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52544029528", "ndc_label_name": "Amethyst Tablet 90-20 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641616601", "ndc_label_name": "Amikacin Sulfate SOLUTION 1 GM/4ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155029042", "ndc_label_name": "Amikacin Sulfate SOLUTION 1 GM/4ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703904003", "ndc_label_name": "Amikacin Sulfate Solution 1 GM/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323081522", "ndc_label_name": "Amikacin Sulfate Solution 1 GM/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021017304", "ndc_label_name": "Amikacin Sulfate SOLUTION 1 GM/4ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155078641", "ndc_label_name": "Amikacin Sulfate Solution 1 GM/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323081504", "ndc_label_name": "Amikacin Sulfate SOLUTION 1 GM/4ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641616610", "ndc_label_name": "Amikacin Sulfate SOLUTION 1 GM/4ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155029032", "ndc_label_name": "Amikacin Sulfate SOLUTION 1 GM/4ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155078631", "ndc_label_name": "Amikacin Sulfate Solution 1 GM/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323081502", "ndc_label_name": "Amikacin Sulfate SOLUTION 500 MG/2ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641616701", "ndc_label_name": "Amikacin Sulfate SOLUTION 500 MG/2ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155029031", "ndc_label_name": "Amikacin Sulfate SOLUTION 500 MG/2ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703903203", "ndc_label_name": "Amikacin Sulfate Solution 500 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641616710", "ndc_label_name": "Amikacin Sulfate SOLUTION 500 MG/2ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155029041", "ndc_label_name": "Amikacin Sulfate SOLUTION 500 MG/2ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155078531", "ndc_label_name": "Amikacin Sulfate Solution 500 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323081521", "ndc_label_name": "Amikacin Sulfate Solution 500 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703903201", "ndc_label_name": "Amikacin Sulfate Solution 500 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155078541", "ndc_label_name": "Amikacin Sulfate Solution 500 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021017302", "ndc_label_name": "Amikacin Sulfate SOLUTION 500 MG/2ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268007115", "ndc_label_name": "aMILoride HCl Tablet 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884011701", "ndc_label_name": "AMILoride HCl TABLET 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268007111", "ndc_label_name": "aMILoride HCl Tablet 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574029201", "ndc_label_name": "AMILoride HCl TABLET 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980015101", "ndc_label_name": "AMILoride HCl Tablet 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884011710", "ndc_label_name": "AMILoride HCl TABLET 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378057701", "ndc_label_name": "aMILoride-hydroCHLOROthiazide Tablet 5-50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378057705", "ndc_label_name": "aMILoride-hydroCHLOROthiazide Tablet 5-50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555048302", "ndc_label_name": "aMILoride-hydroCHLOROthiazide Tablet 5-50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555048305", "ndc_label_name": "aMILoride-hydroCHLOROthiazide Tablet 5-50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722003523", "ndc_label_name": "Aminocaproic Acid Solution 0.25 GM/ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52817081508", "ndc_label_name": "Aminocaproic Acid Solution 0.25 GM/ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651057308", "ndc_label_name": "Aminocaproic Acid Solution 0.25 GM/ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054110058", "ndc_label_name": "Aminocaproic Acid Solution 0.25 GM/ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238159608", "ndc_label_name": "Aminocaproic Acid Solution 0.25 GM/ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478044708", "ndc_label_name": "Aminocaproic Acid Solution 0.25 GM/ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66689033008", "ndc_label_name": "Aminocaproic Acid Solution 0.25 GM/ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69315050324", "ndc_label_name": "Aminocaproic Acid Solution 0.25 GM/ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69680011408", "ndc_label_name": "Aminocaproic Acid Solution 0.25 GM/ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70377010411", "ndc_label_name": "Aminocaproic Acid Solution 0.25 GM/ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687050525", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687073995", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904716507", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60219163703", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478076830", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687073925", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72205004930", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62559022530", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687050595", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69315023103", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24658079830", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69680011530", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238163703", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70377010211", "ndc_label_name": "Aminocaproic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409592216", "ndc_label_name": "Aminophylline Solution 25 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409592201", "ndc_label_name": "Aminophylline SOLUTION 25 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409592116", "ndc_label_name": "Aminophylline Solution 25 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409592101", "ndc_label_name": "Aminophylline SOLUTION 25 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42494030703", "ndc_label_name": "Amiodarone HCl Tablet 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672405506", "ndc_label_name": "Amiodarone HCl TABLET 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862024030", "ndc_label_name": "Amiodarone HCl TABLET 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714084301", "ndc_label_name": "Amiodarone HCl Tablet 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862015430", "ndc_label_name": "Amiodarone HCl TABLET 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687043701", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714084402", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382022714", "ndc_label_name": "Amiodarone HCl TABLET 200 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185014409", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185014405", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904655661", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862073205", "ndc_label_name": "Amiodarone HCl TABLET 200 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084037111", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714084401", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862073260", "ndc_label_name": "Amiodarone HCl TABLET 200 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862024190", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185014460", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672402504", "ndc_label_name": "Amiodarone HCl TABLET 200 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862024105", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084037101", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862024160", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382022705", "ndc_label_name": "Amiodarone HCl TABLET 200 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687043711", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739038710", "ndc_label_name": "Amiodarone HCl Tablet 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356050060", "ndc_label_name": "Amitiza Capsule 24 MCG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23635052460", "ndc_label_name": "Amitiza Capsule 24 MCG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64764024060", "ndc_label_name": "Amitiza Capsule 24 MCG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629459801", "ndc_label_name": "Amitiza Capsule 24 MCG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64764008060", "ndc_label_name": "Amitiza Capsule 8 MCG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23635050860", "ndc_label_name": "Amitiza Capsule 8 MCG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378261010", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709030", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353030653", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378261001", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709085", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781148610", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544015230", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221221", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781148601", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709081", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000815", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261045960", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999020530", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714044602", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714044601", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221232", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544025030", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261045910", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000860", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436307102", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090003006", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729017101", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261045990", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729017117", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002230", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353030680", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002049130", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079013101", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090302606", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261045912", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017201", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261045902", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002260", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999020500", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217027360", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079013120", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002049160", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261045930", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017208", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261045920", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090302600", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436307105", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217027390", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017204", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217027330", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000840", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006407", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002215", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079013163", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000850", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289012430", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006402", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006406", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017200", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760021290", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353030630", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000820", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002049100", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700024190", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006405", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700064330", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700024100", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919011730", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353030660", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000890", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664068718", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629137003", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001130", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629137002", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700064390", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031110", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999020560", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289012412", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629137001", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031140", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919011760", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629137005", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031101", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001860", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090003000", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700024130", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629137004", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031177", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629137006", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031115", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031102", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710122501", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090003001", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664068788", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788221206", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001830", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031120", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031124", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031104", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788221203", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090302601", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864002430", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335039506", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788632006", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031130", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031190", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031112", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788632009", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436307101", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760021230", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335039508", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69158000000", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031174", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001890", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710122500", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335039502", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000802", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001190", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788901309", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335039504", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959000830", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788901306", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335039500", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335039507", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017206", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031160", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335039503", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335039509", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017207", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335039501", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335039505", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031172", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760021215", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544020630", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001160", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544020660", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874031150", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788221209", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788632003", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788632008", "ndc_label_name": "Amitriptyline HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788901303", "ndc_label_name": "Amitriptyline HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054221", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221621", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709485", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221625", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709481", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378268501", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436307401", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261062630", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054240", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261062660", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729017501", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700039130", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781149001", "ndc_label_name": "Amitriptyline HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709490", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569214602", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356074130", "ndc_label_name": "Amitriptyline HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629336206", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079056301", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261062690", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710122901", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714045001", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063019360", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868243300", "ndc_label_name": "Amitriptyline HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079056320", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356074330", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054215", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090033302", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335004005", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054228", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054242", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864075730", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054230", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959054214", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569214603", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629336202", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569214601", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267056090", "ndc_label_name": "Amitriptyline HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664069088", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700066030", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868243302", "ndc_label_name": "Amitriptyline HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919022330", "ndc_label_name": "Amitriptyline HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629336201", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629336205", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919022360", "ndc_label_name": "Amitriptyline HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629336203", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629336204", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335004001", "ndc_label_name": "Amitriptyline HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378269501", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781149101", "ndc_label_name": "Amitriptyline HCl TABLET 150 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714045101", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261094490", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629430401", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261094460", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221721", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868243402", "ndc_label_name": "Amitriptyline HCl TABLET 150 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729017601", "ndc_label_name": "Amitriptyline HCl TABLET 150 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919037430", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261094430", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629430403", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335056601", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919037445", "ndc_label_name": "Amitriptyline HCl TABLET 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664069188", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629430402", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710123001", "ndc_label_name": "Amitriptyline HCl Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378262501", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709185", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378262510", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709194", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709181", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221302", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781148710", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709190", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709130", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544015690", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709160", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221332", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709191", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781148701", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714044702", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063086328", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221321", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002300", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709192", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729017201", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356071230", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544015630", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729017217", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436270304", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904020161", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002320", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221330", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356071200", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063086330", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "12634040171", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006315", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217026930", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714044701", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002330", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544010930", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006300", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353016353", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356071290", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090003104", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017500", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082230", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002360", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353016330", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006360", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006330", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006350", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090284000", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006504", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090284008", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356071260", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006390", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436307201", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090003100", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090003108", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436270302", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006505", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436307205", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353016360", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002033960", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436307202", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090003101", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090284001", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034812", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687043301", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079010701", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034850", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017504", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034802", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436270301", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090284004", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034815", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001290", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034810", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002033900", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006500", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034814", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034890", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079010720", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034860", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919028930", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006502", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006503", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289073001", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034820", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002033930", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079010763", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017508", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187040815", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289073025", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289073060", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289073012", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700060090", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217026960", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034800", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001230", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136902", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289073030", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864002215", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664068818", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760036730", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217026990", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034830", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187040890", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136905", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289073090", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919028990", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687043311", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919028960", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017501", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55154566500", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136910", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043020", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700060000", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136904", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760036760", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243000603", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569017502", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118211306", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043014", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043040", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700060060", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136907", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136908", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001930", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006508", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864002230", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710122601", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043090", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118211403", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043001", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043004", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544008575", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700060030", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136901", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043030", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243000609", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118211406", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043025", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043050", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544008580", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664068888", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788221303", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243024209", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243024203", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760036700", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043028", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267100600", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934007130", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136903", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788221306", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544008560", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116028030", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001260", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043060", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136906", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335125402", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187040860", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788682506", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136909", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001990", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043002", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335030600", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001914", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001991", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874043015", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335030606", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267001960", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544008553", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544008570", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335030603", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544008530", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335030602", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788682503", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335030609", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788682509", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335030605", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788682508", "ndc_label_name": "Amitriptyline HCl TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335030608", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710122600", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69158000100", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335030601", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335030604", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335030607", "ndc_label_name": "Amitriptyline HCl Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709230", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781148810", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221421", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356074290", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378265001", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709291", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378265010", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709294", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709260", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544011030", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729017317", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353016453", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709281", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781148801", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709292", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904020261", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709285", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035800", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999022830", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353016460", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714044802", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544015790", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714044801", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729017301", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709290", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035828", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090026405", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090297200", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356074230", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035860", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035803", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035802", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221432", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035890", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436307302", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051420", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353016430", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356074260", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035820", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035807", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436371001", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002400", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051400", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051421", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090026402", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999022860", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035830", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035814", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569151901", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002430", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051460", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051490", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090255300", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079013320", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999022800", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261035821", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006605", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063083630", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569151905", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700061960", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090255302", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051410", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006602", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002460", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001660", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090026400", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569912600", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035904", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436307301", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569151900", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001630", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090255301", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001360", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090026401", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687044401", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035940", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700061930", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569151902", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760021430", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687044411", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919007630", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090255305", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187015530", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710122701", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664068918", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868006606", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136805", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136801", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187035930", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079013301", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035902", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335036602", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001371", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700061990", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035901", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136806", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136808", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051401", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035920", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335036603", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919024060", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136804", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035990", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035915", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035950", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959051430", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002030", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335036605", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136803", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544025330", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544025360", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788074803", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035960", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664068988", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002060", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335125604", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035928", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69158000200", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788074809", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788074806", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544025353", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864002330", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788706108", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335036604", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002090", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760017230", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335036601", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335036606", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544025370", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001330", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788706106", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335036607", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788706103", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001390", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710122700", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919007660", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335036608", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136802", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629136807", "ndc_label_name": "Amitriptyline HCl TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035914", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874035930", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788706109", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335125602", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335125603", "ndc_label_name": "Amitriptyline HCl Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709330", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036330", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036390", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063033660", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781148901", "ndc_label_name": "Amitriptyline HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709385", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378267501", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036360", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221521", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063033630", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440709381", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959028460", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079014701", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603221525", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356075930", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999090960", "ndc_label_name": "Amitriptyline HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436307501", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436017401", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868235702", "ndc_label_name": "Amitriptyline HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868235703", "ndc_label_name": "Amitriptyline HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959028430", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714044901", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919054190", "ndc_label_name": "Amitriptyline HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760018130", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874029601", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629359702", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629359703", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664069288", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874029604", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729017401", "ndc_label_name": "Amitriptyline HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874029660", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874029615", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874029690", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874029640", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788643201", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629359701", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874029620", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079014720", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788643203", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874029630", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788643208", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788643209", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788643206", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629359704", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335017301", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959028400", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710122801", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700068930", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760022130", "ndc_label_name": "Amitriptyline HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72511048201", "ndc_label_name": "Amjevita Solution Auto-Injector 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72511048202", "ndc_label_name": "Amjevita Solution Auto-Injector 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513048202", "ndc_label_name": "Amjevita Solution Auto-Injector 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513048201", "ndc_label_name": "Amjevita Solution Auto-Injector 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "84612048202", "ndc_label_name": "Amjevita Solution Auto-Injector 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090642800", "ndc_label_name": "Amjevita Solution Auto-Injector 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513040002", "ndc_label_name": "Amjevita Solution Auto-Injector 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513040001", "ndc_label_name": "Amjevita Solution Auto-Injector 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72511040001", "ndc_label_name": "Amjevita Solution Auto-Injector 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72511040002", "ndc_label_name": "Amjevita Solution Auto-Injector 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72511048102", "ndc_label_name": "Amjevita Solution Auto-Injector 80 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513048101", "ndc_label_name": "Amjevita Solution Auto-Injector 80 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513048102", "ndc_label_name": "Amjevita Solution Auto-Injector 80 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72511048101", "ndc_label_name": "Amjevita Solution Auto-Injector 80 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "84612048102", "ndc_label_name": "Amjevita Solution Auto-Injector 80 MG/0.8ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513047901", "ndc_label_name": "Amjevita Solution Prefilled Syringe 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "84612047902", "ndc_label_name": "Amjevita Solution Prefilled Syringe 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72511047901", "ndc_label_name": "Amjevita Solution Prefilled Syringe 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513047902", "ndc_label_name": "Amjevita Solution Prefilled Syringe 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72511047902", "ndc_label_name": "Amjevita Solution Prefilled Syringe 40 MG/0.4ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513041001", "ndc_label_name": "Amjevita Solution Prefilled Syringe 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090641100", "ndc_label_name": "Amjevita Solution Prefilled Syringe 40 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513041301", "ndc_label_name": "Amjevita-Ped 10kg to <15kg Solution Prefilled Syringe 10 MG/0.2ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72511039901", "ndc_label_name": "Amjevita-Ped 15kg to <30kg Solution Prefilled Syringe 20 MG/0.2ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513039901", "ndc_label_name": "Amjevita-Ped 15kg to <30kg Solution Prefilled Syringe 20 MG/0.2ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "84612039901", "ndc_label_name": "Amjevita-Ped 15kg to <30kg Solution Prefilled Syringe 20 MG/0.2ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513041101", "ndc_label_name": "Amjevita-Ped 15kg to <30kg Solution Prefilled Syringe 20 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714390", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082500", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090141801", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591376001", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093737301", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714381", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714385", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093737310", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014605", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082590", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058605", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378689801", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063023230", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591376005", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781227401", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714330", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180075801", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090141800", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180047201", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082530", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082560", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781227410", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084072633", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034101", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569648300", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919085290", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063023260", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001013000", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569648301", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084072632", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014601", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034105", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335080303", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058601", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378690001", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090146300", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569655300", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781227901", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090272000", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093767101", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014705", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111058601", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058705", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090328500", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180076001", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058701", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591376201", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187037030", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014701", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180047301", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001013100", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 10-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591375701", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093737001", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714085", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082360", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111033801", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 2.5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378689501", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082390", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714030", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781227101", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714081", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063017114", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714090", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014201", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 2.5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082330", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 2.5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180075501", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 2.5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001013200", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 2.5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058201", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 2.5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378689601", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714130", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714190", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082400", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714185", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093737110", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781227201", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093737101", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001013300", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714181", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569593700", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591375801", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082430", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591375805", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090103900", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014305", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014301", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082460", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111033901", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058301", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058305", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781227210", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082490", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111033905", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063023360", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180075601", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569593800", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714230", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261098290", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378689701", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093737201", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714285", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093737210", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781227301", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034001", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591375901", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356096030", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090104201", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714281", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591375905", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063023460", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781227310", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180075701", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261098200", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440714290", "ndc_label_name": "amLODIPine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063040260", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063057190", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014401", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090104200", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569593801", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058405", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261098230", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205012230", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034005", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629145401", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014405", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261098260", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058401", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180045901", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001013400", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781227701", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090304900", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093767001", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090340400", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356096530", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014501", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378689901", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569655200", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058501", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180075901", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591376101", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862058505", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090335700", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001013500", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090164400", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111058701", "ndc_label_name": "Amlodipine Besy-Benazepril HCl CAPSULE 5-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237014505", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180046301", "ndc_label_name": "Amlodipine Besy-Benazepril HCl Capsule 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054010231", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054010222", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054010228", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378521077", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509830", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509800", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093716898", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378521005", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300024305", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603211016", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509881", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709890", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509885", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509890", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063040490", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509805", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053530", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052603", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008515", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904637161", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709881", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709830", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090152901", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509860", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053590", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052610", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569590201", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544016430", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603211032", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603211002", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959020990", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709885", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342001610", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053502", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700054190", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300024310", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603211060", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603211028", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289029990", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603211033", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063040430", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063004130", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664005713", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063004190", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42582031518", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806005705", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664005718", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052605", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353069160", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353053430", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762213509", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008511", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806005709", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353053445", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760013290", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052690", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569590200", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353098945", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629156501", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700001518", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806005710", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353069130", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919046030", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300024319", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700054130", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090258100", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645051654", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700001560", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353053460", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353098960", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919080590", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053560", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664005799", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045201", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544099331", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762154004", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353098930", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547023211", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638603", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42582031509", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762154002", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111027105", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680506", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762154005", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547023209", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090152900", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680509", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999024810", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762154003", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111027190", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097012815", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760013230", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664057013", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045220", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282023990", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090258101", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429014590", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700074090", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664057018", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760023990", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687049601", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045256", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664057099", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045230", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687049611", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687027411", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58517012030", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187091430", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629156503", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700001530", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919046090", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289029930", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544099360", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187032690", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919078290", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862010390", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877019905", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700074030", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187091490", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762213501", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084026001", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739063110", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862010399", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180072109", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180075203", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762154001", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544099315", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919078230", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645058054", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862010305", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544099330", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788173703", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69150011501", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687027401", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877019990", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629156502", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021802", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645044570", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021805", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680501", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335079901", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760023930", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282023910", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544099345", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645051670", "ndc_label_name": "AmLODIPine Besylate TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71093014803", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084026011", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877019910", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680503", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021804", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180072103", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071070730", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71093014806", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335079902", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180075209", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071134900", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021801", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638601", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382012305", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638606", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382012316", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097012805", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638609", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934006730", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097083805", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097083815", "ndc_label_name": "amLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69150011510", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335021803", "ndc_label_name": "AmLODIPine Besylate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709681", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509660", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509605", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709630", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054010031", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093008398", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509630", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054010022", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052405", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709685", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904636961", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603210802", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378520805", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603210828", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709690", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378520877", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42582031318", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603210832", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052490", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300024105", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509681", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052410", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806005509", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509600", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045020", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082630", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082660", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959091090", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052403", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300024119", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547023011", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509685", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664056899", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090162701", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700073830", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569646700", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082600", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063076430", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569646701", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603210825", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762152001", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008311", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084025801", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111026990", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261082690", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547023009", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664005518", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300024110", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762224203", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762152002", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382012105", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289044830", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806005505", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045066", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187078390", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42582031309", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687028501", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762224209", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788678109", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664005599", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045001", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180071909", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877019705", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806005510", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862010190", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687028511", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69150011310", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862010199", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429014390", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788678103", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180075009", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008315", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788725901", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919075390", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097012605", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382012116", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187078310", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788678106", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097012615", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664005513", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69150011301", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877019710", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335083302", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788678101", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629367801", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788725903", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282023710", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664056813", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71093014605", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097083615", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788725909", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788725906", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664056818", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282023790", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760024030", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71093014603", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760024090", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187078330", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862010105", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877019790", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084025811", "ndc_label_name": "AmLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097083605", "ndc_label_name": "amLODIPine Besylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603210925", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093716755", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509760", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054010128", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093716798", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054010122", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509705", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709785", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603210928", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378520977", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709790", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054010131", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509730", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378520905", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509781", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052505", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603210932", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509700", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603210934", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509785", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440509790", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709730", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16252054590", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300024205", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300024210", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440709781", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052503", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603210902", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261043730", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052590", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42582031418", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261043700", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356005960", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544016230", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135052510", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904637061", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547023111", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261043760", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353025145", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261043790", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063056430", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29300024219", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806005605", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261043702", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569590101", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342001510", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547023109", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356074010", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045120", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356085890", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353068415", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356005910", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111027090", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356085830", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090252400", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806005609", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111027005", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063056490", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353068445", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356005930", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289027090", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42582031409", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090252401", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353025160", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664005613", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353054545", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353068460", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356005990", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700054330", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353025115", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045101", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090152700", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687048811", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569590100", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008411", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356073910", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664005699", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353025130", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762153002", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008415", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629156605", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700054360", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700054390", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806005610", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429014490", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353068430", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762153005", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045156", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862010299", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664005618", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664056913", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959091130", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760023830", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090152701", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687026301", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664056918", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645051554", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762153006", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664056999", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569905400", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862010290", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090287600", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687026311", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919084490", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645051570", "ndc_label_name": "AmLODIPine Besylate TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762201001", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762201009", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289027030", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180072009", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079045169", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629156601", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629156603", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680303", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919029571", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919084430", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762153001", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788173803", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959091190", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862010205", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544097945", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680306", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180072003", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877019810", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762153004", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680309", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762153003", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544097915", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877019805", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693501", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180075103", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877019890", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762201003", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69150011490", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687048801", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544097930", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382012205", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69150011401", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097012705", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071134800", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760023890", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335038901", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919029530", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180075109", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335038902", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335038903", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097012715", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382012216", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919084460", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335047307", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629156604", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680301", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335038904", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097083705", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934007530", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71093014706", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919084471", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097083715", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071072830", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335038907", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335038905", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71093014703", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335047305", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335047301", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629156602", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335038906", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693503", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335047303", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335047306", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335083402", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693506", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335047304", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544097960", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282023890", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282023810", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084025901", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084025911", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645044470", "ndc_label_name": "AmLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693509", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335047302", "ndc_label_name": "amLODIPine Besylate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43386008209", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-160 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378172293", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-160 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291012830", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093769198", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781562831", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884057511", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291002230", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093769156", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862073930", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-160 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068730", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668020630", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332020630", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-160 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43386008203", "ndc_label_name": "amLODIPine Besylate-Valsartan Tablet 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332020690", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180076506", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093769398", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862074030", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-320 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291012930", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43386008003", "ndc_label_name": "amLODIPine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068830", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291002330", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378172493", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-320 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093769356", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668020430", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332020830", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-320 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43386008009", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-320 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884057711", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090320900", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180076706", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781564331", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090247100", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569668200", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332020890", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 10-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093769056", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378172193", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-160 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291002030", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668020730", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291012630", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093769098", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43386008303", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-160 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781561531", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332020530", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-160 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332020590", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43386008309", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-160 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862073730", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-160 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068530", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180076406", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884057411", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291002130", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378172393", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-320 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332020730", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-320 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068630", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093769256", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093769298", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862073830", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-320 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43386008109", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668020530", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781563931", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43386008103", "ndc_label_name": "amLODIPine Besylate-Valsartan Tablet 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884057611", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332020790", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291012730", "ndc_label_name": "Amlodipine Besylate-Valsartan TABLET 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180076606", "ndc_label_name": "Amlodipine Besylate-Valsartan Tablet 5-320 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451793", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451705", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762673001", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 10-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598032190", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598032130", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762673007", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 10-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304059030", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 10-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598031890", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451893", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762673101", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 10-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451805", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304059130", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 10-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598031830", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762673107", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 10-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451905", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598031590", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762673201", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 10-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451993", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762673207", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 10-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598031530", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304050030", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 10-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304060330", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 10-80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378452093", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-80 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598031330", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 10-80 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762673301", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 10-80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304050130", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 2.5-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598032330", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 2.5-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762671001", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 2.5-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378451093", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 2.5-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762671101", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 2.5-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378451193", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 2.5-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598032030", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 2.5-20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304050230", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 2.5-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378451293", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 2.5-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598031730", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 2.5-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304050330", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 2.5-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762671201", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 2.5-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762672001", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 5-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451305", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304058730", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 5-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598032290", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762672007", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 5-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451393", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598032230", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451493", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304058830", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 5-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762672101", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 5-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598031930", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762672107", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 5-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598031990", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451405", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451505", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451593", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304058930", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 5-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762672207", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 5-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762672201", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 5-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598031630", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598031690", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762672301", "ndc_label_name": "amLODIPine-Atorvastatin Tablet 5-80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304049930", "ndc_label_name": "Amlodipine-Atorvastatin Tablet 5-80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378451693", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-80 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598031430", "ndc_label_name": "Amlodipine-Atorvastatin TABLET 5-80 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093702998", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571023630", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668031230", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332021490", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093702956", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241008503", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342019207", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241008509", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664077399", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664077383", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668031290", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862085630", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342019210", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462056730", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505458403", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877050030", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332021430", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877050090", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462056790", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664077583", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668031130", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093703098", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342019310", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093703056", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668031190", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241008609", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332021530", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664077599", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571023830", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241008603", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862085730", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877050290", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505458503", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332021590", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462056930", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342019307", "ndc_label_name": "Amlodipine-Olmesartan TABLET 10-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877050230", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462056990", "ndc_label_name": "Amlodipine-Olmesartan Tablet 10-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668032430", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093702798", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668032490", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342019007", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571023530", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241008303", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462056630", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093702756", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332021290", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664077299", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664077283", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241008309", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862085430", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505458203", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462056690", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342019010", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332021230", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877049990", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877049930", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342019107", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664077483", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862085530", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093702898", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093702856", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668031390", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241008403", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241008409", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342019110", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571023730", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462056830", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332021330", "ndc_label_name": "Amlodipine-Olmesartan TABLET 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668031330", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664077499", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462056890", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332021390", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505458303", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877050130", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877050190", "ndc_label_name": "Amlodipine-Olmesartan Tablet 5-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862083630", "ndc_label_name": "amLODIPine-Valsartan-HCTZ Tablet 10-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093781056", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781576031", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180077206", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884017409", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093781098", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668032730", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884017411", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180077209", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884018511", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093703856", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180077409", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668032830", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862083730", "ndc_label_name": "amLODIPine-Valsartan-HCTZ Tablet 10-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093703898", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180077406", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781578731", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884018509", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180077509", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-320-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862083830", "ndc_label_name": "amLODIPine-Valsartan-HCTZ Tablet 10-320-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781579431", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-320-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093780956", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-320-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093780998", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-320-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884017511", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-320-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884017509", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-320-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668032530", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-320-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180077506", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 10-320-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180077106", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781575631", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862083430", "ndc_label_name": "amLODIPine-Valsartan-HCTZ Tablet 5-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093780798", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884017211", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884017209", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093780756", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180077109", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668032630", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862083530", "ndc_label_name": "amLODIPine-Valsartan-HCTZ Tablet 5-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093703798", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093703756", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884017309", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884017311", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781577131", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668032930", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180077306", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180077309", "ndc_label_name": "Amlodipine-Valsartan-HCTZ Tablet 5-160-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672130104", "ndc_label_name": "Ammonium Lactate CREAM 12 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672130100", "ndc_label_name": "Ammonium Lactate CREAM 12 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802049326", "ndc_label_name": "Ammonium Lactate CREAM 12 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63044040420", "ndc_label_name": "Ammonium Lactate CREAM 12 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802049383", "ndc_label_name": "Ammonium Lactate CREAM 12 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802041926", "ndc_label_name": "Ammonium Lactate LOTION 12 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672130009", "ndc_label_name": "Ammonium Lactate LOTION 12 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672130005", "ndc_label_name": "Ammonium Lactate LOTION 12 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802041954", "ndc_label_name": "Ammonium Lactate LOTION 12 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63044048409", "ndc_label_name": "Ammonium Lactate LOTION 12 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00378661185", "ndc_label_name": "Amnesteem CAPSULE 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378661193", "ndc_label_name": "Amnesteem CAPSULE 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378661285", "ndc_label_name": "Amnesteem CAPSULE 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378661293", "ndc_label_name": "Amnesteem CAPSULE 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378661493", "ndc_label_name": "Amnesteem CAPSULE 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378661485", "ndc_label_name": "Amnesteem CAPSULE 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60923022702", "ndc_label_name": "Amondys 45 Solution 100 MG/2ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591571501", "ndc_label_name": "Amoxapine Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591571630", "ndc_label_name": "Amoxapine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591571301", "ndc_label_name": "Amoxapine Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591571401", "ndc_label_name": "Amoxapine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781405442", "ndc_label_name": "Amoxicill-Clarithro-Lansopraz Therapy Pack 500 & 500 & 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993041882", "ndc_label_name": "Amoxicill-Clarithro-Lansopraz Therapy Pack 500 & 500 & 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993041864", "ndc_label_name": "Amoxicill-Clarithro-Lansopraz Therapy Pack 500 & 500 & 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781405432", "ndc_label_name": "Amoxicill-Clarithro-Lansopraz Therapy Pack 500 & 500 & 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237000114", "ndc_label_name": "Amoxicill-Clarithro-Lansopraz Therapy Pack 500 & 500 & 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57237000101", "ndc_label_name": "Amoxicill-Clarithro-Lansopraz Therapy Pack 500 & 500 & 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440710009", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143993805", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093310701", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710006", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093310705", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143993801", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710030", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544011730", "ndc_label_name": "Amoxicillin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781202031", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710003", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029801", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781202001", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440110030", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001506", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781202005", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022501", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002510", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781202076", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063057404", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42582021310", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710004", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063057421", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002520", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959001124", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002530", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029802", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063057415", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001560", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959001121", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999001621", "ndc_label_name": "Amoxicillin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001515", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310703", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001504", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42582021318", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001924", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090182600", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959001130", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999001630", "ndc_label_name": "Amoxicillin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001521", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700016630", "ndc_label_name": "Amoxicillin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001530", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063057430", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629125704", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569174600", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348054530", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090182601", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001524", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864002830", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001540", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022505", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010101", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001906", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569174609", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310701", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999001604", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010120", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063057406", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959001120", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010118", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700030830", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310700", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310706", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959001160", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010145", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436721803", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569833800", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014410", "ndc_label_name": "Amoxicillin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003005", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116065921", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001915", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569174601", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116027230", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959001140", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001921", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543010310", "ndc_label_name": "Amoxicillin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010128", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014450", "ndc_label_name": "Amoxicillin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001960", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310709", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002115", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002020830", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629422601", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003001", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788636904", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543010350", "ndc_label_name": "Amoxicillin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700056030", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002105", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001601", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569174602", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629125705", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629125703", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788636903", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70882011330", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010103", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010124", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934008730", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569174605", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010105", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001605", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010115", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310707", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010130", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788636902", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010140", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001930", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010150", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289001940", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002130", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629125701", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934015494", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629125702", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010109", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010121", "ndc_label_name": "Amoxicillin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002121", "ndc_label_name": "Amoxicillin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143993905", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544000721", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093310953", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440110130", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143993901", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093310905", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710130", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544054620", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710104", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544061921", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544000730", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710103", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710109", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710106", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013730", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544054621", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781261301", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013710", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544054615", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781261305", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544001821", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544001830", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002830", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544061930", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544061942", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013740", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013712", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781261331", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544054630", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013728", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001709", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029904", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029902", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001760", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013715", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781261376", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013714", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002800", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001715", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013760", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029903", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063043440", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002840", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544054640", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001706", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002810", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056306", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013784", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42582021418", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056360", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002845", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544054660", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001714", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002821", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056309", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002816", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001740", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082015", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42582021410", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "15749082510", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001728", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054230", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056328", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002820", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056321", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082021", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001721", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013720", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054208", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054240", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056340", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001730", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999001506", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082040", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001724", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013721", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054215", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056308", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056363", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054228", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030205", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030100", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001742", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002860", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054221", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056314", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082006", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082014", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030300", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436003104", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001750", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356098521", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056330", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056356", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999001508", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020501", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002021", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002020", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001756", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356098530", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082008", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020505", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999001542", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999001520", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217021730", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002040", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063043421", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001763", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082028", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030102", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999001545", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030107", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348055021", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021615", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063043430", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054206", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082030", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030207", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030206", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090318700", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569186108", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021640", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054209", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030101", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063091530", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030301", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436010602", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002060", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569333504", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310900", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054214", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030204", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436003101", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436010601", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002028", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021621", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569572700", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002006", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054260", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002005", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002000", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002018", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569186101", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348055030", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002021", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002050", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056315", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002024", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021642", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021660", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569186102", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569186100", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700000721", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919035520", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082004", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217021710", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310901", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217021720", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002015", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569186105", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002230", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919035530", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082056", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348055006", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002004", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569186109", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002056", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002024", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001620", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919099420", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030105", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569572701", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002009", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569333507", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700000740", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002030", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187039930", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629421601", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030400", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569675400", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002014", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569830000", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700007521", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002040", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629123600", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629421701", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002004", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310909", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002028", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310906", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700020721", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002063", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010250", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010201", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002006", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700000730", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002060", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002201", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700040621", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700000742", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267076404", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010215", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002030", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700037430", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700007530", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001630", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003101", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700007520", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788637403", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010218", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002042", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001660", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864002930", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629123601", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864002940", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700007560", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003320", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116066030", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021630", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919066621", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919099430", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629123602", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187039921", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700037421", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003392", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002308", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021656", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187039910", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629123608", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629123604", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629123607", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003105", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005492", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253015050", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569333505", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010205", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010204", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010228", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629123609", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919066610", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010214", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788903303", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569333506", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010220", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002304", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116028930", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629426501", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187039920", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002309", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116066821", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310902", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010230", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002340", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002320", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001701", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187039960", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788897204", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002330", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310907", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002360", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788903302", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788637402", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002315", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629123603", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788978602", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788637404", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310908", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629123605", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003394", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788714103", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002321", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629123606", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005430", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788714104", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002042", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629426401", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005440", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788897202", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70882011420", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010203", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700040609", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543010410", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003321", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010210", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700041630", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010212", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005420", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001705", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002205", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788978603", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005421", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788978604", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187004430", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003330", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005493", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629421801", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005494", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010209", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76439010410", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010221", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010224", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010240", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010245", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788714102", "ndc_label_name": "Amoxicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788897203", "ndc_label_name": "Amoxicillin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543010450", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003393", "ndc_label_name": "Amoxicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093415080", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781603955", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781603958", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988880", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781603946", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093415073", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093415079", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988801", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090040400", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999019180", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090040600", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022253", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022280", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569292800", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988815", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022252", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090300500", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959018101", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959018108", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999019100", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959018100", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187020015", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261060201", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959018180", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868415002", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862070601", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014647", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021493", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862070655", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788901901", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014645", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217011901", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205026615", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217031201", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788994901", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868415001", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862070680", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569293000", "ndc_label_name": "Amoxicillin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014646", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988601", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988675", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093416076", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093416078", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022351", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988650", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093416073", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862007050", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781615646", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217031601", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217024901", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781615657", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959084301", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919039932", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781615652", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022350", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868446800", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919067232", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261076601", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022352", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014743", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788732301", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003201", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003250", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862007001", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003275", "ndc_label_name": "Amoxicillin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014744", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014740", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862007075", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093415579", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093415573", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988915", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999016800", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093415580", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988980", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217031401", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999016880", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988901", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261046001", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781604158", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002020991", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020953", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020980", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868415500", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868415504", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781604146", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261072601", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020952", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788901701", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919071633", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090041100", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862070701", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868415501", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781604155", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002020993", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999016850", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862070755", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862070780", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001533", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014845", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267099315", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090040500", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187018615", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090040700", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788994801", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090225100", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267099400", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071152608", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014846", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569292900", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569662600", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569293100", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868415502", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569295400", "ndc_label_name": "Amoxicillin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187088015", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014847", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781615757", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093416176", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988775", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988750", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090134700", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700046800", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999058500", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093416173", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020750", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781615752", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999098300", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919040132", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569603700", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003301", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020751", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093416178", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700046700", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020752", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569555300", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788731801", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862007175", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919063375", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569640100", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143988701", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014943", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090108600", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868510100", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781615746", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788901801", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253014944", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868510102", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261046301", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862007150", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959029605", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788903501", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090085800", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868510101", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003350", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003375", "ndc_label_name": "Amoxicillin Suspension Reconstituted 400 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862007101", "ndc_label_name": "Amoxicillin SUSPENSION RECONSTITUTED 400 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569518200", "ndc_label_name": "Amoxicillin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090182500", "ndc_label_name": "Amoxicillin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781506020", "ndc_label_name": "Amoxicillin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093226301", "ndc_label_name": "Amoxicillin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090070900", "ndc_label_name": "Amoxicillin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001401", "ndc_label_name": "Amoxicillin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781506001", "ndc_label_name": "Amoxicillin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022401", "ndc_label_name": "Amoxicillin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934014730", "ndc_label_name": "Amoxicillin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001405", "ndc_label_name": "Amoxicillin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237002801", "ndc_label_name": "Amoxicillin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143928501", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093226401", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143995101", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710220", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090071100", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143995120", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544043420", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048830", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143928520", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544089620", "ndc_label_name": "Amoxicillin TABLET 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544095006", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710230", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090071302", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781506101", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048820", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598021901", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048800", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048807", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048802", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356098420", "ndc_label_name": "Amoxicillin TABLET 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436454301", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781506120", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090071102", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598021914", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048821", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048890", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048814", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063088520", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217021028", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048828", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002001320", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959066130", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090071300", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090071301", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002920", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090071200", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868454300", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048860", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289070728", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569519300", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217021014", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919036620", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356098320", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569519302", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868454302", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090071400", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001501", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569833400", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700068720", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788076302", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959066120", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569835400", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919004120", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436002901", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788897702", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868454303", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919013520", "ndc_label_name": "Amoxicillin TABLET 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868454301", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003891", "ndc_label_name": "Amoxicillin TABLET 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919001720", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629287101", "ndc_label_name": "Amoxicillin TABLET 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237002920", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003894", "ndc_label_name": "Amoxicillin TABLET 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289070720", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629423701", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187032514", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205003520", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116067520", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267130902", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237002901", "ndc_label_name": "Amoxicillin TABLET 875 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003814", "ndc_label_name": "Amoxicillin TABLET 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788716002", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205003514", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934006414", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934006491", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934006494", "ndc_label_name": "Amoxicillin Tablet 875 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093226701", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002630", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093226805", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034104", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710503", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093226801", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710509", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710504", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090045500", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002645", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002664", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959024621", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261046220", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710514", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710530", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358002684", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310503", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090045400", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310501", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569368900", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261046240", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261046230", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959024640", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999003300", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289018214", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090045401", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569368901", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919042430", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261046260", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959024630", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569368905", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090045405", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864067540", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959024619", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868310500", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629175903", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289018290", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002230", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289018209", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569833300", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629175901", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289018206", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289018240", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700033230", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116016830", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289018230", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629175904", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864067530", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116060830", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629175902", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934014030", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629426301", "ndc_label_name": "Amoxicillin Tablet Chewable 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629175905", "ndc_label_name": "Amoxicillin TABLET CHEWABLE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781194339", "ndc_label_name": "Amoxicillin-Pot Clavulanate ER Tablet Extended Release 12 Hour 1000-62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022028", "ndc_label_name": "Amoxicillin-Pot Clavulanate ER Tablet Extended Release 12 Hour 1000-62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781194382", "ndc_label_name": "Amoxicillin-Pot Clavulanate ER Tablet Extended Release 12 Hour 1000-62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022040", "ndc_label_name": "Amoxicillin-Pot Clavulanate ER Tablet Extended Release 12 Hour 1000-62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261042801", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143998175", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143998101", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378083335", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029202", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569548800", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093227773", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781610246", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862053350", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919039332", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143998150", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862053375", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029203", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788715501", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029201", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598021350", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999035600", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598021351", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598021352", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862053301", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 200-28.5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090083200", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66685101101", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66685101100", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788899601", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 200-28.5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651002601", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 250-62.5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651002675", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 250-62.5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020451", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 250-62.5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651002655", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 250-62.5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432006500", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 250-62.5 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020452", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 250-62.5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432006575", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 250-62.5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72508020410", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 250-62.5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72508020407", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 250-62.5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432006547", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 250-62.5 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020453", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 250-62.5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72508020415", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 250-62.5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569548700", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090092800", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143998250", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029302", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143998275", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261046401", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378083609", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093227973", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569568900", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217028601", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029303", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261098901", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378083435", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090083100", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090304700", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143998201", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862053450", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66685101201", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261098801", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862053401", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781610446", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569569000", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090330900", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378083675", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66685101200", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788712801", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187082600", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029301", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919039132", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862053475", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 400-57 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66685101202", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 400-57 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029403", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985316", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093867574", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378083520", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985324", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093867575", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985375", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781613957", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862053502", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378083534", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781613948", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569583100", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781613954", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093867578", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029401", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020369", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862053513", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029402", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090099600", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700047125", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020351", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378083575", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261060001", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862053575", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090185700", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090329300", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788895601", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788682907", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217022001", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020354", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053875", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788682901", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187085775", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569604300", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432007046", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919069334", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788997001", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788712707", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432007048", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187085720", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60432007075", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788895607", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788712701", "ndc_label_name": "Amoxicillin-Pot Clavulanate Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788997007", "ndc_label_name": "Amoxicillin-Pot Clavulanate SUSPENSION RECONSTITUTED 600-42.9 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714047601", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 250-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42571016030", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 250-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862050130", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 250-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598021830", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 250-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781187431", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 250-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70882011120", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 250-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029501", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 250-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356098220", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261011220", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378083094", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093227434", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710703", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710730", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710704", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714049401", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090254703", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42571016142", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029601", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781183120", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070215", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436605103", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999024620", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003020", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070220", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090254701", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356098215", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714047701", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547003", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070209", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090254702", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070204", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070230", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002023920", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598020614", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42571016101", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700037515", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289084506", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070212", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547001", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187080320", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547002", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090254700", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436605101", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205001420", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071006330", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070240", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289084520", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629289504", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700018120", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070221", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070214", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267085704", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864077730", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547000", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629289505", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66685100200", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629289502", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547004", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700041820", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005314", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629423901", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289084530", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874122602", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005394", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267085703", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289084521", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629289503", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629289501", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267100101", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289084528", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788706702", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071154502", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66685100202", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700037520", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005714", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788972502", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788905502", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862050220", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788996002", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005794", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934012630", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071006306", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 500-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70882011220", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 500-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378083194", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710804", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143924920", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710802", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029701", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710830", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378083201", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093227534", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714047802", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710820", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440710803", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714029702", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261011114", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544095106", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063007706", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714047801", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003120", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090082101", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781185220", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063007704", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356098120", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "12634080771", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598022114", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42571016242", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42571016201", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090082102", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261011120", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090082103", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063007703", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356098114", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547103", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063037702", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070760", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090317903", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090082100", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090317901", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090317900", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090317905", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700010620", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090231405", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267085903", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436100101", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090082105", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070710", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090317902", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070714", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700030614", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289076720", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003991", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436312901", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547102", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700065320", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070715", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547104", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700030620", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919020220", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72508022114", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070720", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289076728", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864076720", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700010614", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547105", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700044420", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919066520", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919043020", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959070730", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700045614", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919052120", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003910", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289076710", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919002020", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187042320", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700065314", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002078920", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071403202", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919066514", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700075120", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289076730", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788904302", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187048820", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187042314", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547100", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788972602", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187042310", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629124801", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187001420", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003994", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267071203", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629124804", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569547101", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934008620", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629124802", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862050301", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187042328", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267071230", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267071210", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66685100100", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289076714", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071422402", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862050320", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071496702", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267071221", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267085902", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289076721", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66685100101", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267100201", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267085904", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919020210", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003914", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919063720", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071154602", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187032720", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205033120", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629124803", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934016291", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874111202", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267071214", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788931902", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET 875-125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788996102", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934011091", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934011094", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet 875-125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093227034", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet Chewable 200-28.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093227234", "ndc_label_name": "Amoxicillin-Pot Clavulanate TABLET CHEWABLE 400-57 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217007820", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet Chewable 400-57 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034203", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet Chewable 400-57 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569563800", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet Chewable 400-57 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569563801", "ndc_label_name": "Amoxicillin-Pot Clavulanate Tablet Chewable 400-57 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00480368301", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664095088", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406080301", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00480368401", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664095188", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406080701", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 37.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00480368501", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 37.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664095288", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 37.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00480368601", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406080401", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664095388", "ndc_label_name": "Amphet-Dextroamphet 3-Bead ER Capsule Extended Release 24 Hour 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52536005910", "ndc_label_name": "Amphetamine Sulfate Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69238156401", "ndc_label_name": "Amphetamine Sulfate Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70010004101", "ndc_label_name": "Amphetamine Sulfate Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52536005710", "ndc_label_name": "Amphetamine Sulfate Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69238156301", "ndc_label_name": "Amphetamine Sulfate Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70010004001", "ndc_label_name": "Amphetamine Sulfate Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115148701", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687027625", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406895201", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781233501", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884084001", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858061001", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115132901", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993059502", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228305911", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43975033210", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555078702", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687027695", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555079102", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406895301", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115133001", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884084101", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858021501", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993059602", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228306311", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115148801", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687028795", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781234301", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43975033310", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687028725", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115148901", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406895401", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858072001", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228306011", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43975033410", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687029825", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884084201", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115133101", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781235201", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555078802", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687029833", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687029895", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993059702", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555079202", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43975033510", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406895501", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115133201", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993059802", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115149001", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228306411", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858032501", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884084301", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781236801", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687023232", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115133301", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555078902", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884084401", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406895601", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228306111", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687022132", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115149101", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858093001", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781237101", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687022133", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993059902", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43975033610", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43975033110", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858005501", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115132801", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555079002", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406895101", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228306211", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993059402", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884083901", "ndc_label_name": "Amphetamine-Dextroamphet ER Capsule Extended Release 24 Hour 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115148601", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781232901", "ndc_label_name": "Amphetamine-Dextroamphet ER CAPSULE EXTENDED RELEASE 24 HOUR 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378454301", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406889201", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228304811", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806034101", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527150237", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714080401", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185084201", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781017601", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343016201", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64720013210", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555097202", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664064308", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289068060", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107007001", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714095001", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289068090", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629373001", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382095201", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664064408", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527150337", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343016301", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228304911", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555077602", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382095301", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378454401", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714080501", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64720013310", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714095101", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406888501", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378454501", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555077702", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806034301", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343016401", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714080601", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228305011", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382095401", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64720013410", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527150437", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107007201", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714095201", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664064508", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107007301", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228305111", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714095301", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555097302", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806034401", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714080701", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64720013510", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185085301", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378454601", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406889301", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781017901", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527150537", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664064608", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343016501", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382095501", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629373101", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107007401", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378454701", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185086401", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527150637", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806034501", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714080801", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714095401", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406889401", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228305211", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555097402", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781018001", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64720013610", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343016601", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664064708", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382095601", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107006801", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714094801", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228304611", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806033901", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378454101", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555097102", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185083101", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343016001", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714080201", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289070030", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406889101", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64720013010", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527150037", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382095001", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664064108", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289070090", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289070060", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629373201", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555077502", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 7.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228304711", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527150137", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714080301", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343016101", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378454201", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714094901", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406888401", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664064208", "ndc_label_name": "Amphetamine-Dextroamphetamine TABLET 7.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64720013110", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382095101", "ndc_label_name": "Amphetamine-Dextroamphetamine Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358003320", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440711640", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959038928", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003330", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011401", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781214501", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959038940", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781214505", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011407", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959038920", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002404", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003340", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002420", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544012228", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002407", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002430", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002401", "ndc_label_name": "Ampicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569241101", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011421", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999011720", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253018110", "ndc_label_name": "Ampicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959038930", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011424", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011440", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002528", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629261002", "ndc_label_name": "Ampicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005928", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002410", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002428", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629261003", "ndc_label_name": "Ampicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011410", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011420", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289002440", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011430", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011425", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002530", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629261001", "ndc_label_name": "Ampicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788713901", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629426601", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011403", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011428", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002540", "ndc_label_name": "Ampicillin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253018150", "ndc_label_name": "Ampicillin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781926185", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794022241", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781340495", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860011415", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781940495", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781940485", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781340485", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409372601", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65219001810", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457035101", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781926195", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409372610", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021013610", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457035110", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485042110", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011310", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794022202", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67850002100", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567010210", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65219001801", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008602", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860011441", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603036301", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008601", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572001601", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485042101", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67850002110", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572001610", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603036310", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409372511", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781940946", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011599", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781340946", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860011899", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781340995", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409372501", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781940995", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603057801", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567010401", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008801", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794022415", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457040410", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781940178", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 125 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781340095", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 125 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781340078", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 125 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781940195", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 125 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781341315", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781341392", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781941315", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781941392", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409371810", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781925078", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781340795", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65219001610", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781925095", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781340778", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409371801", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603022110", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021013510", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011210", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457035010", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794022141", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65219001601", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781940795", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781940778", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67850002410", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567010110", "ndc_label_name": "Ampicillin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860011341", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008501", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323070800", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794022102", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457035050", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008502", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603022101", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67850002400", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860011315", "ndc_label_name": "Ampicillin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641611601", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 1.5 (1-0.5) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288000520", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288003121", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794020641", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011610", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011601", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021014220", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 1.5 (1-0.5) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641611610", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 1.5 (1-0.5) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021018620", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572002101", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603022001", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288003191", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794024102", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794020602", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288000521", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781303295", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567021010", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 1.5 (1-0.5) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457034810", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572002110", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603022010", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485041610", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008101", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794024141", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011620", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 1.5 (1-0.5) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485041601", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008102", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288003120", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288003192", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 1.5 (1-0.5) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008301", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567021201", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011899", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641611801", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288000775", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288003391", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794020815", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781303446", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603044401", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011801", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457064910", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021014499", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288003375", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021018899", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794024315", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 15 (10-5) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641611710", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 3 (2-1) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781303370", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011720", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 3 (2-1) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021018730", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641612301", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641611701", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 3 (2-1) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008202", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641612310", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 3 (2-1) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794020741", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567021110", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 3 (2-1) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288003221", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794024241", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567015010", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021014330", "ndc_label_name": "Ampicillin-Sulbactam Sodium SOLUTION RECONSTITUTED 3 (2-1) GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288003291", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781303395", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011701", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457034910", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288003292", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603033501", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008201", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794024202", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603033510", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150011710", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485041701", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288003220", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572002210", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794020702", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572002201", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288000630", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485041710", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288000631", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409298703", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409298723", "ndc_label_name": "Ampicillin-Sulbactam Sodium Solution Reconstituted 3 (2-1) GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10144042760", "ndc_label_name": "Ampyra Tablet Extended Release 12 Hour 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569606402", "ndc_label_name": "Amrix Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459070060", "ndc_label_name": "Amrix Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356026210", "ndc_label_name": "Amrix Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356026260", "ndc_label_name": "Amrix Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569606400", "ndc_label_name": "Amrix Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569606401", "ndc_label_name": "Amrix Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63459070160", "ndc_label_name": "Amrix Capsule Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73776000111", "ndc_label_name": "Amtagvi Suspension 72000000000 CELLS Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71336100301", "ndc_label_name": "Amvuttra Solution Prefilled Syringe 25 MG/0.5ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868485600", "ndc_label_name": "Anadrol-50 TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68220005510", "ndc_label_name": "Anadrol-50 Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406990603", "ndc_label_name": "Anafranil CAPSULE 25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406990703", "ndc_label_name": "Anafranil CAPSULE 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406990803", "ndc_label_name": "Anafranil CAPSULE 75 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904619546", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261095790", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093753656", "ndc_label_name": "Anastrozole TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378603477", "ndc_label_name": "Anastrozole TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378603405", "ndc_label_name": "Anastrozole TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729003515", "ndc_label_name": "Anastrozole TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054016413", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261095730", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16571042103", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268007515", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756025083", "ndc_label_name": "Anastrozole TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781535631", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569619800", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261095700", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63323012930", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063038315", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729003510", "ndc_label_name": "Anastrozole TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991062033", "ndc_label_name": "Anastrozole TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382020910", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991062010", "ndc_label_name": "Anastrozole TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729003516", "ndc_label_name": "Anastrozole TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261095760", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788677403", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429028630", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063038306", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001015504", "ndc_label_name": "Anastrozole TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788677406", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687011211", "ndc_label_name": "Anastrozole TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090245300", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66435041530", "ndc_label_name": "Anastrozole TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788677409", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72789000815", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268007511", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382020906", "ndc_label_name": "Anastrozole TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111064730", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687011221", "ndc_label_name": "Anastrozole TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505298503", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756025013", "ndc_label_name": "Anastrozole TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001015508", "ndc_label_name": "Anastrozole TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69117000301", "ndc_label_name": "Anastrozole Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187355410", "ndc_label_name": "Ancobon CAPSULE 250 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187355510", "ndc_label_name": "Ancobon CAPSULE 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69853010201", "ndc_label_name": "Andexxa Solution Reconstituted 200 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023599002", "ndc_label_name": "Androderm Patch 24 Hour 2 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52544007660", "ndc_label_name": "Androderm Patch 24 Hour 2 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00023599060", "ndc_label_name": "Androderm Patch 24 Hour 2 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52544007654", "ndc_label_name": "Androderm Patch 24 Hour 2 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52544007754", "ndc_label_name": "Androderm Patch 24 Hour 4 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00023599230", "ndc_label_name": "Androderm Patch 24 Hour 4 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00023599204", "ndc_label_name": "Androderm Patch 24 Hour 4 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52544007730", "ndc_label_name": "Androderm Patch 24 Hour 4 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00051846231", "ndc_label_name": "AndroGel Gel 20.25 MG/1.25GM (1.62%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00051846212", "ndc_label_name": "AndroGel Gel 20.25 MG/1.25GM (1.62%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00051842501", "ndc_label_name": "AndroGel Gel 25 MG/2.5GM (1%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00051842530", "ndc_label_name": "AndroGel Gel 25 MG/2.5GM (1%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00051846201", "ndc_label_name": "AndroGel Gel 40.5 MG/2.5GM (1.62%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00051846230", "ndc_label_name": "AndroGel Gel 40.5 MG/2.5GM (1.62%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00051845001", "ndc_label_name": "AndroGel Gel 50 MG/5GM (1%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00051845030", "ndc_label_name": "AndroGel Gel 50 MG/5GM (1%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569533901", "ndc_label_name": "AndroGel Gel 50 MG/5GM (1%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356037605", "ndc_label_name": "AndroGel Gel 50 MG/5GM (1%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569533900", "ndc_label_name": "AndroGel Gel 50 MG/5GM (1%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633700", "ndc_label_name": "AndroGel Pump Gel 20.25 MG/ACT (1.62%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00051846233", "ndc_label_name": "AndroGel Pump Gel 20.25 MG/ACT (1.62%) Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419048203", "ndc_label_name": "Angeliq TABLET 0.25-0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419048201", "ndc_label_name": "Angeliq TABLET 0.25-0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419048303", "ndc_label_name": "Angeliq TABLET 0.5-1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419048301", "ndc_label_name": "Angeliq TABLET 0.5-1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868618400", "ndc_label_name": "Angeliq TABLET 0.5-1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50261031301", "ndc_label_name": "Annovera Ring 0.013-0.15 MG/24HR Vaginal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173086910", "ndc_label_name": "Anoro Ellipta Aerosol Powder Breath Activated 62.5-25 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173086906", "ndc_label_name": "Anoro Ellipta Aerosol Powder Breath Activated 62.5-25 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00113058840", "ndc_label_name": "Antacid Anti-Gas Max Strength Suspension 400-400-40 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800047848", "ndc_label_name": "Antacid Calcium Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800047847", "ndc_label_name": "Antacid Calcium TABLET CHEWABLE 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68084098832", "ndc_label_name": "Antacid Calcium TABLET CHEWABLE 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536104815", "ndc_label_name": "Antacid Calcium TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68084098833", "ndc_label_name": "Antacid Calcium TABLET CHEWABLE 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536122522", "ndc_label_name": "Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113046880", "ndc_label_name": "Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000046001", "ndc_label_name": "Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205020580", "ndc_label_name": "Antacid Extra Strength TABLET CHEWABLE 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205070680", "ndc_label_name": "Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113048980", "ndc_label_name": "Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000043002", "ndc_label_name": "Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000043101", "ndc_label_name": "Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800085140", "ndc_label_name": "Antacid Fast Relief Suspension 200-200-20 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113035740", "ndc_label_name": "Antacid Plus Anti-Gas Relief Suspension 200-200-20 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000003401", "ndc_label_name": "Antacid Regular Strength Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205031440", "ndc_label_name": "Antacid Suspension 200-200-20 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000047601", "ndc_label_name": "Antacid Suspension 200-200-20 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113085140", "ndc_label_name": "Antacid Suspension 200-200-20 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58659201506", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113048547", "ndc_label_name": "Antacid Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00363022434", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58659201503", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00182113920", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00363031734", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205020047", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58659201606", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65504031111", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58659201603", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205021047", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65504091011", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49614047847", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65504090911", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58659201509", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "75450029576", "ndc_label_name": "Antacid TABLET CHEWABLE 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000043601", "ndc_label_name": "Antacid Ultra Strength Tablet Chewable 1000 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000045901", "ndc_label_name": "Antacid Ultra Strength Tablet Chewable 1000 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "27437010706", "ndc_label_name": "Antara Capsule 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27437010806", "ndc_label_name": "Antara Capsule 90 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00536199553", "ndc_label_name": "Anti-Dandruff SHAMPOO 1 % EXTERNAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800052024", "ndc_label_name": "Anti-Diarrheal Capsule 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000023001", "ndc_label_name": "Anti-Diarrheal Capsule 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800052012", "ndc_label_name": "Anti-Diarrheal Capsule 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000046101", "ndc_label_name": "Anti-Diarrheal Capsule 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205037067", "ndc_label_name": "Anti-Diarrheal Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904772524", "ndc_label_name": "Anti-Diarrheal TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113022453", "ndc_label_name": "Anti-Diarrheal TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113022489", "ndc_label_name": "Anti-Diarrheal Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51660012312", "ndc_label_name": "Anti-Diarrheal Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904772512", "ndc_label_name": "Anti-Diarrheal TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800022462", "ndc_label_name": "Anti-Diarrheal TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800022453", "ndc_label_name": "Anti-Diarrheal TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113022462", "ndc_label_name": "Anti-Diarrheal TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800022491", "ndc_label_name": "Anti-Diarrheal TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113022491", "ndc_label_name": "Anti-Diarrheal TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205037089", "ndc_label_name": "Anti-Diarrheal Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800022480", "ndc_label_name": "Anti-Diarrheal Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205037053", "ndc_label_name": "Anti-Diarrheal Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113097364", "ndc_label_name": "Anti-Itch Maximum Strength CREAM 1 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113054164", "ndc_label_name": "Anti-Itch Maximum Strength CREAM 1 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536130297", "ndc_label_name": "Anti-Nausea Solution 1.87-1.87-21.5 Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917004542", "ndc_label_name": "Anti-Nausea SOLUTION 1.87-1.87-21.5 ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67777023111", "ndc_label_name": "Antifungal (Clotrimazole) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68001047545", "ndc_label_name": "Antifungal (Clotrimazole) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67777023110", "ndc_label_name": "Antifungal (Clotrimazole) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67777023112", "ndc_label_name": "Antifungal (Clotrimazole) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67777023113", "ndc_label_name": "Antifungal (Clotrimazole) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68001047547", "ndc_label_name": "Antifungal (Clotrimazole) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41520031353", "ndc_label_name": "Antifungal (Tolnaftate) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904072236", "ndc_label_name": "Antifungal (Tolnaftate) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41268092069", "ndc_label_name": "Antifungal (Tolnaftate) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205019710", "ndc_label_name": "Antifungal (Tolnaftate) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090016000", "ndc_label_name": "Antifungal (Tolnaftate) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536127211", "ndc_label_name": "Antifungal Clotrimazole Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536127222", "ndc_label_name": "Antifungal Clotrimazole Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00472073556", "ndc_label_name": "Antifungal Cream 2 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00472073514", "ndc_label_name": "Antifungal Cream 2 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63187088515", "ndc_label_name": "Antifungal Cream 2 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "76077040004", "ndc_label_name": "Antifungal CREAM 2 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68788737402", "ndc_label_name": "Antifungal Cream 2 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00472073542", "ndc_label_name": "Antifungal Cream 2 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090223100", "ndc_label_name": "Antifungal Cream 2 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "76077040007", "ndc_label_name": "Antifungal CREAM 2 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000063701", "ndc_label_name": "Antifungal Maximum Strength Solution 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000032301", "ndc_label_name": "Antifungal POWDER 2 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536124207", "ndc_label_name": "Antihistamine & Nasal Deconges Tablet Extended Release 12 Hour 60-120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536124234", "ndc_label_name": "Antihistamine & Nasal Deconges Tablet Extended Release 12 Hour 60-120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54629077660", "ndc_label_name": "Antioxidant CAPSULE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536103706", "ndc_label_name": "Antioxidant Formula Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70199000401", "ndc_label_name": "Antivert Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70199001801", "ndc_label_name": "Antivert Tablet Chewable 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "30698012005", "ndc_label_name": "Anzemet Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10702034001", "ndc_label_name": "Apadaz Tablet 4.08-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10702034101", "ndc_label_name": "Apadaz Tablet 6.12-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10702034201", "ndc_label_name": "Apadaz Tablet 8.16-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788891806", "ndc_label_name": "APAP-Caff-Dihydrocodeine Capsule 320.5-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217019560", "ndc_label_name": "APAP-Caff-Dihydrocodeine Capsule 320.5-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629685103", "ndc_label_name": "APAP-Caff-Dihydrocodeine CAPSULE 320.5-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42195084010", "ndc_label_name": "APAP-Caff-Dihydrocodeine Capsule 320.5-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217019590", "ndc_label_name": "APAP-Caff-Dihydrocodeine Capsule 320.5-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629685101", "ndc_label_name": "APAP-Caff-Dihydrocodeine CAPSULE 320.5-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217019530", "ndc_label_name": "APAP-Caff-Dihydrocodeine Capsule 320.5-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629685102", "ndc_label_name": "APAP-Caff-Dihydrocodeine CAPSULE 320.5-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788891809", "ndc_label_name": "APAP-Caff-Dihydrocodeine Capsule 320.5-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788891803", "ndc_label_name": "APAP-Caff-Dihydrocodeine Capsule 320.5-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71993030030", "ndc_label_name": "APAP-Caff-Dihydrocodeine Tablet 325-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68047072001", "ndc_label_name": "APAP-Caff-Dihydrocodeine Tablet 325-30-16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10337039530", "ndc_label_name": "ApexiCon E Cream 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10337039560", "ndc_label_name": "ApexiCon E Cream 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82737007301", "ndc_label_name": "Aphexda Solution Reconstituted 62 MG Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00088250205", "ndc_label_name": "Apidra SoloStar Solution Pen-injector 100 UNIT/ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00088250033", "ndc_label_name": "Apidra SOLUTION 100 UNIT/ML INJECTION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187581030", "ndc_label_name": "Aplenzin Tablet Extended Release 24 Hour 174 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187581130", "ndc_label_name": "Aplenzin Tablet Extended Release 24 Hour 348 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187581230", "ndc_label_name": "Aplenzin Tablet Extended Release 24 Hour 522 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "18407063105", "ndc_label_name": "Aplicare Alcohol Swabstick Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "27505000405", "ndc_label_name": "Apokyn Solution Cartridge 30 MG/3ML Subcutaneous", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "27505000401", "ndc_label_name": "Apokyn Solution Cartridge 30 MG/3ML Subcutaneous", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52817072001", "ndc_label_name": "Apomorphine HCl Solution Cartridge 30 MG/3ML Subcutaneous", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52817072005", "ndc_label_name": "Apomorphine HCl Solution Cartridge 30 MG/3ML Subcutaneous", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478071611", "ndc_label_name": "Apraclonidine HCl Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478071610", "ndc_label_name": "Apraclonidine HCl Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314066505", "ndc_label_name": "Apraclonidine HCl Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314066510", "ndc_label_name": "Apraclonidine HCl Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13668059487", "ndc_label_name": "Aprepitant 80 & 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781232306", "ndc_label_name": "Aprepitant Capsule 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781232368", "ndc_label_name": "Aprepitant CAPSULE 125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462058576", "ndc_label_name": "Aprepitant CAPSULE 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462058540", "ndc_label_name": "Aprepitant CAPSULE 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781232106", "ndc_label_name": "Aprepitant CAPSULE 40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462058340", "ndc_label_name": "Aprepitant CAPSULE 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781232151", "ndc_label_name": "Aprepitant CAPSULE 40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462058385", "ndc_label_name": "Aprepitant CAPSULE 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462011233", "ndc_label_name": "Aprepitant CAPSULE 80 & 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781406336", "ndc_label_name": "Aprepitant CAPSULE 80 & 125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781232246", "ndc_label_name": "Aprepitant CAPSULE 80 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462058476", "ndc_label_name": "Aprepitant CAPSULE 80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781232268", "ndc_label_name": "Aprepitant CAPSULE 80 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462058440", "ndc_label_name": "Aprepitant CAPSULE 80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462058458", "ndc_label_name": "Aprepitant CAPSULE 80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49702023803", "ndc_label_name": "Apretude Suspension Extended Release 600 MG/3ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49702026423", "ndc_label_name": "Apretude Suspension Extended Release 600 MG/3ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555904358", "ndc_label_name": "Apri TABLET 0.15-30 MG-MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555904379", "ndc_label_name": "Apri TABLET 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090248100", "ndc_label_name": "Apri Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569487800", "ndc_label_name": "Apri Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65649010302", "ndc_label_name": "Apriso Capsule Extended Release 24 Hour 0.375 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353088479", "ndc_label_name": "Apriso Capsule Extended Release 24 Hour 0.375 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59088071100", "ndc_label_name": "Aprizio Pak Kit 2.5-2.5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42858040145", "ndc_label_name": "Aptensio XR Capsule Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858040245", "ndc_label_name": "Aptensio XR Capsule Extended Release 24 Hour 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858040345", "ndc_label_name": "Aptensio XR Capsule Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858040445", "ndc_label_name": "Aptensio XR Capsule Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858040545", "ndc_label_name": "Aptensio XR Capsule Extended Release 24 Hour 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858040645", "ndc_label_name": "Aptensio XR Capsule Extended Release 24 Hour 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858040745", "ndc_label_name": "Aptensio XR Capsule Extended Release 24 Hour 60 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63402020230", "ndc_label_name": "Aptiom TABLET 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63402020430", "ndc_label_name": "Aptiom TABLET 400 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63402020660", "ndc_label_name": "Aptiom TABLET 600 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63402020830", "ndc_label_name": "Aptiom TABLET 800 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597000302", "ndc_label_name": "Aptivus CAPSULE 250 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569571900", "ndc_label_name": "Aptivus Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597000201", "ndc_label_name": "Aptivus Solution 100 MG/ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "38415051208", "ndc_label_name": "Aqua Lance Adjustable Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60913000101", "ndc_label_name": "AquaLance Lancets 30G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "72140003270", "ndc_label_name": "Aquaphor Itch Relief Children Ointment 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00944281501", "ndc_label_name": "Aralast NP SOLUTION RECONSTITUTED 1000 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00944281401", "ndc_label_name": "Aralast NP SOLUTION RECONSTITUTED 500 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555906667", "ndc_label_name": "Aranelle TABLET 0.5/1/0.5-35 MG-MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555906679", "ndc_label_name": "Aranelle TABLET 0.5/1/0.5-35 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513000501", "ndc_label_name": "Aranesp (Albumin Free) SOLUTION 100 MCG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513000504", "ndc_label_name": "Aranesp (Albumin Free) SOLUTION 100 MCG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513000601", "ndc_label_name": "Aranesp (Albumin Free) SOLUTION 200 MCG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513000201", "ndc_label_name": "Aranesp (Albumin Free) SOLUTION 25 MCG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513000204", "ndc_label_name": "Aranesp (Albumin Free) SOLUTION 25 MCG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513000304", "ndc_label_name": "Aranesp (Albumin Free) SOLUTION 40 MCG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513000301", "ndc_label_name": "Aranesp (Albumin Free) SOLUTION 40 MCG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513000401", "ndc_label_name": "Aranesp (Albumin Free) SOLUTION 60 MCG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513000404", "ndc_label_name": "Aranesp (Albumin Free) SOLUTION 60 MCG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513009804", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 10 MCG/0.4ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513009801", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 10 MCG/0.4ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513002501", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 100 MCG/0.5ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513002504", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 100 MCG/0.5ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513002701", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 150 MCG/0.3ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513002704", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 150 MCG/0.3ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513002801", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 200 MCG/0.4ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513005701", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 25 MCG/0.42ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513005704", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 25 MCG/0.42ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513011101", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 300 MCG/0.6ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513002101", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 40 MCG/0.4ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513002104", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 40 MCG/0.4ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513003201", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 500 MCG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513002301", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 60 MCG/0.3ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513002304", "ndc_label_name": "Aranesp (Albumin Free) Solution Prefilled Syringe 60 MCG/0.3ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187209845", "ndc_label_name": "Arazlo Lotion 0.045 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61755000101", "ndc_label_name": "Arcalyst Solution Reconstituted 220 MG Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58160084811", "ndc_label_name": "Arexvy Suspension Reconstituted 120 MCG/0.5ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332063304", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332063360", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093595511", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097016853", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687077079", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093595556", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687077083", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093595506", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756027702", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70748025730", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093595545", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70756061270", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462083365", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687077084", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756027703", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332063301", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097016864", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436015157", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332063330", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097016832", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72603020860", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436015158", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436015120", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436015119", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70748017530", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70756061212", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462083335", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70748025760", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70748017560", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72603020801", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097016887", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70756061260", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70756061244", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72603020830", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72603020804", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76204002601", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76204002602", "ndc_label_name": "Arformoterol Tartrate Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544009215", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49848000690", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544009217", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999075490", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864089530", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105073703", "ndc_label_name": "Aricept TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544009288", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289015121", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105073709", "ndc_label_name": "Aricept TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544009232", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289015130", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62856024630", "ndc_label_name": "Aricept TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544009289", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629363201", "ndc_label_name": "Aricept Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62856024730", "ndc_label_name": "Aricept TABLET 23 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62856024530", "ndc_label_name": "Aricept TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864088630", "ndc_label_name": "Aricept Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49848000590", "ndc_label_name": "Aricept Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105073909", "ndc_label_name": "Aricept TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105073903", "ndc_label_name": "Aricept TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71558059028", "ndc_label_name": "Arikayce Suspension 590 MG/8.4ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356027030", "ndc_label_name": "Arimidex Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310020130", "ndc_label_name": "Arimidex Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559067030", "ndc_label_name": "Arimidex Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59651011055", "ndc_label_name": "ARIPiprazole Solution 1 MG/ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505040405", "ndc_label_name": "ARIPiprazole SOLUTION 1 MG/ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54838057059", "ndc_label_name": "ARIPiprazole SOLUTION 1 MG/ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162089374", "ndc_label_name": "ARIPiprazole SOLUTION 1 MG/ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729028001", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021830", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729028010", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904651106", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093758056", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021805", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068110", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021890", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291013530", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068130", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005308", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904651161", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722082730", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353014745", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714078501", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353014715", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598055630", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332009931", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342012407", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005303", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291009730", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008915", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547030403", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043201", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569909000", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162089803", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "48433011710", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008911", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429044830", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788692106", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687017901", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043203", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267403", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788692102", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066305", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282004630", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267408", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788692109", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332009930", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687017911", "ndc_label_name": "ARIPiprazole TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788692101", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162089809", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066330", "ndc_label_name": "ARIPiprazole TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788692103", "ndc_label_name": "ARIPiprazole Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729028101", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904651204", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021990", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093758156", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021905", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714078601", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291009830", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342012507", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729028110", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068210", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090282400", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021930", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068230", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291013630", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547030503", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598055730", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005408", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162089903", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429044930", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687019111", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005403", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009011", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "48433011810", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788700606", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009012", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162089909", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267508", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282004730", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722082830", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066405", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090269100", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066430", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267503", "ndc_label_name": "ARIPiprazole TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043301", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687019121", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788700601", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569905500", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332010031", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043303", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332010030", "ndc_label_name": "ARIPiprazole TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788700602", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788700603", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788700609", "ndc_label_name": "ARIPiprazole Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342012207", "ndc_label_name": "ARIPiprazole TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729027810", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811067930", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811067910", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021605", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093761356", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547030203", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904650904", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291009530", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005108", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291013330", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714078301", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021690", "ndc_label_name": "ARIPiprazole TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722081930", "ndc_label_name": "ARIPiprazole TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008711", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021630", "ndc_label_name": "ARIPiprazole TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332009730", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687015721", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332009731", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729027801", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005103", "ndc_label_name": "ARIPiprazole TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008712", "ndc_label_name": "ARIPiprazole TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788707603", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598055430", "ndc_label_name": "ARIPiprazole TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788707606", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162089609", "ndc_label_name": "ARIPiprazole TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788707609", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "48433011510", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687015711", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066130", "ndc_label_name": "ARIPiprazole TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429044630", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066105", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505307508", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043001", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505307503", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162089603", "ndc_label_name": "ARIPiprazole TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788707601", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043003", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788707602", "ndc_label_name": "ARIPiprazole Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282004430", "ndc_label_name": "ARIPiprazole TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668022030", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093758256", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668022005", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904651304", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687020211", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068330", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043403", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005503", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068310", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729028201", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722082930", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668022090", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043401", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291009930", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788706309", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353014009", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291013730", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005508", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353014005", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714078701", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788706303", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335041201", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335060902", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353014045", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332010130", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342012607", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598055830", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729028210", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788706301", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335060901", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009111", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547030603", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335041202", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353014015", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429045030", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009112", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267603", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282004830", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267608", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687020221", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788706306", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "48433011910", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332010131", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162090103", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066505", "ndc_label_name": "ARIPiprazole Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162090109", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066530", "ndc_label_name": "ARIPiprazole TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788706302", "ndc_label_name": "ARIPiprazole TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068410", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093758356", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "48433012010", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598055930", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668022105", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904651404", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068430", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714078801", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162090209", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668022130", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009211", "ndc_label_name": "ARIPiprazole TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009212", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722083030", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668022190", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291010030", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066630", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342012707", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729028301", "ndc_label_name": "ARIPiprazole TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429045130", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043501", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291013830", "ndc_label_name": "ARIPiprazole TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729028310", "ndc_label_name": "ARIPiprazole TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547030703", "ndc_label_name": "ARIPiprazole TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005603", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267703", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005608", "ndc_label_name": "ARIPiprazole TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282004930", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353014815", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267708", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353014845", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332010231", "ndc_label_name": "ARIPiprazole TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687021311", "ndc_label_name": "ARIPiprazole TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332010230", "ndc_label_name": "ARIPiprazole TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687021321", "ndc_label_name": "ARIPiprazole TABLET 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066605", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162090203", "ndc_label_name": "ARIPiprazole TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043503", "ndc_label_name": "ARIPiprazole Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005208", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904651006", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093756956", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068010", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788716202", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904651061", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021705", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811068030", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332009830", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904665640", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021730", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018015", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162089709", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714078401", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267303", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722082030", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066205", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668021790", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729027901", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739041310", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043103", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729027910", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788716206", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342012307", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700039930", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547030303", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862066230", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "27241005203", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008811", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598055530", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687016801", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291009630", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687016811", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629699901", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332009831", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291013430", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877043101", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788716209", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788716201", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018079", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788716203", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "48433011610", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282004530", "ndc_label_name": "ARIPiprazole TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268008815", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569905600", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429044730", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267308", "ndc_label_name": "ARIPiprazole Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162089703", "ndc_label_name": "ARIPiprazole TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598073330", "ndc_label_name": "ARIPiprazole Tablet Dispersible 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811069230", "ndc_label_name": "ARIPiprazole Tablet Dispersible 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332010330", "ndc_label_name": "ARIPiprazole TABLET DISPERSIBLE 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42043040003", "ndc_label_name": "ARIPiprazole Tablet Dispersible 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42043040103", "ndc_label_name": "ARIPiprazole Tablet Dispersible 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811069330", "ndc_label_name": "ARIPiprazole Tablet Dispersible 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598073430", "ndc_label_name": "ARIPiprazole Tablet Dispersible 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332010430", "ndc_label_name": "ARIPiprazole TABLET DISPERSIBLE 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65757050003", "ndc_label_name": "Aristada Initio Prefilled Syringe 675 MG/2.4ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65757040401", "ndc_label_name": "Aristada Prefilled Syringe 1064 MG/3.9ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65757040403", "ndc_label_name": "Aristada Prefilled Syringe 1064 MG/3.9ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65757040101", "ndc_label_name": "Aristada Prefilled Syringe 441 MG/1.6ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65757040103", "ndc_label_name": "Aristada Prefilled Syringe 441 MG/1.6ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65757040201", "ndc_label_name": "Aristada Prefilled Syringe 662 MG/2.4ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65757040203", "ndc_label_name": "Aristada Prefilled Syringe 662 MG/2.4ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65757040303", "ndc_label_name": "Aristada Prefilled Syringe 882 MG/3.2ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65757040301", "ndc_label_name": "Aristada Prefilled Syringe 882 MG/3.2ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67457059508", "ndc_label_name": "Arixtra SOLUTION 10 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457059500", "ndc_label_name": "Arixtra SOLUTION 10 MG/0.8ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457059200", "ndc_label_name": "Arixtra SOLUTION 2.5 MG/0.5ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457059210", "ndc_label_name": "Arixtra SOLUTION 2.5 MG/0.5ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457059304", "ndc_label_name": "Arixtra SOLUTION 5 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457059300", "ndc_label_name": "Arixtra SOLUTION 5 MG/0.4ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457059406", "ndc_label_name": "Arixtra SOLUTION 7.5 MG/0.6ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457059400", "ndc_label_name": "Arixtra SOLUTION 7.5 MG/0.6ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180057107", "ndc_label_name": "Armodafinil Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189004130", "ndc_label_name": "Armodafinil Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378343293", "ndc_label_name": "Armodafinil TABLET 150 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781803731", "ndc_label_name": "Armodafinil TABLET 150 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189004160", "ndc_label_name": "Armodafinil Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093309256", "ndc_label_name": "Armodafinil Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919077030", "ndc_label_name": "Armodafinil Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068101", "ndc_label_name": "Armodafinil Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991032390", "ndc_label_name": "Armodafinil Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189004190", "ndc_label_name": "Armodafinil Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862080630", "ndc_label_name": "Armodafinil Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180057102", "ndc_label_name": "Armodafinil Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093309356", "ndc_label_name": "Armodafinil Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591385630", "ndc_label_name": "Armodafinil TABLET 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781804531", "ndc_label_name": "Armodafinil TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180057202", "ndc_label_name": "Armodafinil Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59651004730", "ndc_label_name": "Armodafinil Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862099830", "ndc_label_name": "Armodafinil Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180057207", "ndc_label_name": "Armodafinil Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781805331", "ndc_label_name": "Armodafinil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700051030", "ndc_label_name": "Armodafinil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093309456", "ndc_label_name": "Armodafinil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180057307", "ndc_label_name": "Armodafinil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378343393", "ndc_label_name": "Armodafinil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991032490", "ndc_label_name": "Armodafinil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180057302", "ndc_label_name": "Armodafinil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862080730", "ndc_label_name": "Armodafinil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862080530", "ndc_label_name": "Armodafinil Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093309056", "ndc_label_name": "Armodafinil Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378343193", "ndc_label_name": "Armodafinil TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781802931", "ndc_label_name": "Armodafinil TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180056907", "ndc_label_name": "Armodafinil Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991032290", "ndc_label_name": "Armodafinil Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59310020006", "ndc_label_name": "ArmonAir Digihaler Aerosol Powder Breath Activated 113 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59310031106", "ndc_label_name": "ArmonAir Digihaler Aerosol Powder Breath Activated 232 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59310011406", "ndc_label_name": "ArmonAir Digihaler Aerosol Powder Breath Activated 55 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569091902", "ndc_label_name": "Armour Thyroid Tablet 120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569091900", "ndc_label_name": "Armour Thyroid Tablet 120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00456046101", "ndc_label_name": "Armour Thyroid Tablet 120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289026290", "ndc_label_name": "Armour Thyroid Tablet 120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999028960", "ndc_label_name": "Armour Thyroid Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00456045701", "ndc_label_name": "Armour Thyroid Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999028260", "ndc_label_name": "Armour Thyroid TABLET 180 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00456046201", "ndc_label_name": "Armour Thyroid TABLET 180 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999028228", "ndc_label_name": "Armour Thyroid TABLET 180 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00456046301", "ndc_label_name": "Armour Thyroid TABLET 240 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999028860", "ndc_label_name": "Armour Thyroid Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999028830", "ndc_label_name": "Armour Thyroid Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00456045801", "ndc_label_name": "Armour Thyroid Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090018900", "ndc_label_name": "Armour Thyroid Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999028828", "ndc_label_name": "Armour Thyroid Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063034530", "ndc_label_name": "Armour Thyroid Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569091700", "ndc_label_name": "Armour Thyroid Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868079400", "ndc_label_name": "Armour Thyroid TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569091701", "ndc_label_name": "Armour Thyroid Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00456046401", "ndc_label_name": "Armour Thyroid TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358033630", "ndc_label_name": "Armour Thyroid Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358033660", "ndc_label_name": "Armour Thyroid Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358033760", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090019000", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090019001", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569091800", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00456045901", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999070228", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569091801", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629436804", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629436803", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629436802", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629436801", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999070230", "ndc_label_name": "Armour Thyroid Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569447100", "ndc_label_name": "Armour Thyroid Tablet 90 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090169200", "ndc_label_name": "Armour Thyroid Tablet 90 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999028100", "ndc_label_name": "Armour Thyroid Tablet 90 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00456046001", "ndc_label_name": "Armour Thyroid Tablet 90 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569447101", "ndc_label_name": "Armour Thyroid Tablet 90 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00173087410", "ndc_label_name": "Arnuity Ellipta Aerosol Powder Breath Activated 100 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173087414", "ndc_label_name": "Arnuity Ellipta Aerosol Powder Breath Activated 100 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173087614", "ndc_label_name": "Arnuity Ellipta Aerosol Powder Breath Activated 200 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173087610", "ndc_label_name": "Arnuity Ellipta Aerosol Powder Breath Activated 200 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173088810", "ndc_label_name": "Arnuity Ellipta Aerosol Powder Breath Activated 50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00009766304", "ndc_label_name": "Aromasin TABLET 25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999098630", "ndc_label_name": "Aromasin TABLET 25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382099710", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323063703", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "14789060010", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155086931", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742043810", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "14789060007", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323063710", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69918072001", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69918072002", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155086941", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021022610", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603033910", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70121148301", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70121148307", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69918072010", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "83090000901", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860021710", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710189501", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54879002710", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "83090000910", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710189506", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382099701", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72205017101", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603033901", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72205017107", "ndc_label_name": "Arsenic Trioxide Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781349806", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70121165806", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710189601", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150036601", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781349895", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781349894", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "83090001001", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710161001", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155087041", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "83090001010", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021022706", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150036610", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155087031", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710161006", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710189606", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70121165801", "ndc_label_name": "Arsenic Trioxide Solution 12 MG/6ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "36800054471", "ndc_label_name": "Arthritis Pain Relief Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800054462", "ndc_label_name": "Arthritis Pain Relief Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51660033350", "ndc_label_name": "Arthritis Pain Relief Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51660033301", "ndc_label_name": "Arthritis Pain Relief Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800054478", "ndc_label_name": "Arthritis Pain Relief Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800096647", "ndc_label_name": "Arthritis Pain Relief Tablet Extended Release 650 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000055501", "ndc_label_name": "Arthritis Pain Reliever Gel 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800052601", "ndc_label_name": "Arthritis Pain Reliever Gel 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000055503", "ndc_label_name": "Arthritis Pain Reliever Gel 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000055502", "ndc_label_name": "Arthritis Pain Reliever Gel 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536111825", "ndc_label_name": "Arthritis Pain Relieving Cream 0.075 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35356046760", "ndc_label_name": "Arthrotec TABLET DELAYED RELEASE 50-0.2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053142", "ndc_label_name": "Arthrotec Tablet Delayed Release 50-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053190", "ndc_label_name": "Arthrotec Tablet Delayed Release 50-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053160", "ndc_label_name": "Arthrotec Tablet Delayed Release 50-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025141190", "ndc_label_name": "Arthrotec TABLET DELAYED RELEASE 50-0.2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025141160", "ndc_label_name": "Arthrotec TABLET DELAYED RELEASE 50-0.2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289040615", "ndc_label_name": "Arthrotec Tablet Delayed Release 50-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569609700", "ndc_label_name": "Arthrotec Tablet Delayed Release 50-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053120", "ndc_label_name": "Arthrotec Tablet Delayed Release 50-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053130", "ndc_label_name": "Arthrotec Tablet Delayed Release 50-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289040630", "ndc_label_name": "Arthrotec Tablet Delayed Release 50-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052560", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025142160", "ndc_label_name": "Arthrotec TABLET DELAYED RELEASE 75-0.2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629335902", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629335901", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874094401", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052514", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999098760", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874094415", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569457900", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052520", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874094430", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874094414", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071131000", "ndc_label_name": "Arthrotec TABLET DELAYED RELEASE 75-0.2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959052530", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874094460", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874094420", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629335903", "ndc_label_name": "Arthrotec Tablet Delayed Release 75-0.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071069530", "ndc_label_name": "Arthrotec TABLET DELAYED RELEASE 75-0.2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "17478006235", "ndc_label_name": "Artificial Tears Ointment 83-15 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "17478006012", "ndc_label_name": "Artificial Tears Solution 1.4 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68788635401", "ndc_label_name": "Artificial Tears Solution 1.4 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090228300", "ndc_label_name": "Artificial Tears Solution 1.4 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267092315", "ndc_label_name": "Artificial Tears Solution 1.4 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959004100", "ndc_label_name": "Artificial Tears Solution 1.4 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00338850302", "ndc_label_name": "Artiss SOLUTION External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00338850304", "ndc_label_name": "Artiss SOLUTION External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00338850310", "ndc_label_name": "Artiss SOLUTION External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078066913", "ndc_label_name": "Arzerra Concentrate 100 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078066961", "ndc_label_name": "Arzerra Concentrate 100 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00078069061", "ndc_label_name": "Arzerra Concentrate 1000 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023590118", "ndc_label_name": "Asacol HD Tablet Delayed Release 800 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00430078327", "ndc_label_name": "Asacol HD Tablet Delayed Release 800 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69800025001", "ndc_label_name": "Asceniv Solution 5 GM/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69800025002", "ndc_label_name": "Asceniv Solution 5 GM/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "11694071901", "ndc_label_name": "Asco-Tabs-1000 Tablet 1000 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629295203", "ndc_label_name": "Ascomp-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261080230", "ndc_label_name": "Ascomp-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295202", "ndc_label_name": "Ascomp-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261080260", "ndc_label_name": "Ascomp-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261080290", "ndc_label_name": "Ascomp-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991007401", "ndc_label_name": "Ascomp-Codeine CAPSULE 50-325-40-30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629295201", "ndc_label_name": "Ascomp-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991007405", "ndc_label_name": "Ascomp-Codeine CAPSULE 50-325-40-30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60258014110", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16103035511", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917004629", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917004627", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536329201", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00761009450", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536329210", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904533046", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "62107004610", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205008990", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007521", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007522", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014203", "ndc_label_name": "Ascorbic Acid TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014269", "ndc_label_name": "Ascorbic Acid TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00761009420", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014201", "ndc_label_name": "Ascorbic Acid TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014205", "ndc_label_name": "Ascorbic Acid TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58487002501", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "31604001881", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "30768000517", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014260", "ndc_label_name": "Ascorbic Acid TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "48107004914", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135016513", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135014210", "ndc_label_name": "Ascorbic Acid TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "23490688801", "ndc_label_name": "Ascorbic Acid TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58487002503", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864092099", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "31604001485", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "23490688806", "ndc_label_name": "Ascorbic Acid TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629008602", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "31604001486", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917013938", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "30768045058", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312001515", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292022325", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205008978", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49614050678", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629009210", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864000059", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16103035508", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58487002502", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012841", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292022326", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205008985", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864000060", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629007601", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569267700", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "48107004915", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "62107004601", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312001510", "ndc_label_name": "Ascorbic Acid TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012840", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49999035200", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012794", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312001474", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012842", "ndc_label_name": "Ascorbic Acid Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51991036060", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 10 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762288806", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 10 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332019931", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 10 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42794001710", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 10 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332019960", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 10 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991036017", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 10 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762288801", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 10 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332054460", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 2.5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51991092817", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 2.5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51991092860", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 2.5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762109101", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 2.5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762109106", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 2.5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332054410", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 2.5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42794001610", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762201206", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991035860", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762201201", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332019831", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332019860", "ndc_label_name": "Asenapine Maleate Tablet Sublingual 5 MG Sublingual", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090209700", "ndc_label_name": "Ashlyna Tablet 0.15-0.03 &0.01 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462064691", "ndc_label_name": "Ashlyna TABLET 0.15-0.03 &0.01 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569662000", "ndc_label_name": "Ashlyna Tablet 0.15-0.03 &0.01 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462064693", "ndc_label_name": "Ashlyna TABLET 0.15-0.03 &0.01 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00085134101", "ndc_label_name": "Asmanex (120 Metered Doses) Aerosol Powder Breath Activated 220 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356009914", "ndc_label_name": "Asmanex (14 Metered Doses) Aerosol Powder Breath Activated 220 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00085134106", "ndc_label_name": "Asmanex (14 Metered Doses) Aerosol Powder Breath Activated 220 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00085146102", "ndc_label_name": "Asmanex (30 Metered Doses) Aerosol Powder Breath Activated 110 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00085134107", "ndc_label_name": "Asmanex (30 Metered Doses) Aerosol Powder Breath Activated 220 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00085134102", "ndc_label_name": "Asmanex (60 Metered Doses) Aerosol Powder Breath Activated 220 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00085433301", "ndc_label_name": "Asmanex HFA Aerosol 100 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "78206011201", "ndc_label_name": "Asmanex HFA Aerosol 100 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00085433401", "ndc_label_name": "Asmanex HFA Aerosol 200 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "78206011301", "ndc_label_name": "Asmanex HFA Aerosol 200 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "78206011101", "ndc_label_name": "Asmanex HFA Aerosol 50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00085222201", "ndc_label_name": "Asmanex HFA Aerosol 50 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72694051501", "ndc_label_name": "Asparlas Solution 3750 UNIT/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41167005686", "ndc_label_name": "Aspercreme Lidocaine Liquid 4 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167005810", "ndc_label_name": "Aspercreme Lidocaine Liquid 4 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167005815", "ndc_label_name": "Aspercreme Lidocaine Liquid 4 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167005823", "ndc_label_name": "Aspercreme Lidocaine Liquid 4 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904770470", "ndc_label_name": "Aspir-Low Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904770480", "ndc_label_name": "Aspir-Low Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904770418", "ndc_label_name": "Aspir-Low Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "62107002732", "ndc_label_name": "Aspirin 81 Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "62107002726", "ndc_label_name": "Aspirin 81 Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800002712", "ndc_label_name": "Aspirin Adult Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00603002622", "ndc_label_name": "Aspirin EC Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00603002632", "ndc_label_name": "Aspirin EC Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800027748", "ndc_label_name": "Aspirin EC Low Strength Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00603016921", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536331310", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904201159", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68084084895", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68084084825", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904201360", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536331301", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800042902", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00603016932", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000023702", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904201372", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000023701", "ndc_label_name": "Aspirin EC Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904628889", "ndc_label_name": "Aspirin Low Dose Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904628880", "ndc_label_name": "Aspirin Low Dose Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800027468", "ndc_label_name": "Aspirin Low Dose TABLET CHEWABLE 81 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904679480", "ndc_label_name": "Aspirin Low Dose Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483033463", "ndc_label_name": "Aspirin Low Dose TABLET CHEWABLE 81 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904679489", "ndc_label_name": "Aspirin Low Dose Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800046768", "ndc_label_name": "Aspirin Low Dose TABLET CHEWABLE 81 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904678370", "ndc_label_name": "Aspirin Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904671318", "ndc_label_name": "Aspirin Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483038710", "ndc_label_name": "Aspirin Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483038712", "ndc_label_name": "Aspirin Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000042801", "ndc_label_name": "Aspirin Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483048112", "ndc_label_name": "Aspirin Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536123441", "ndc_label_name": "Aspirin Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483048110", "ndc_label_name": "Aspirin Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904675180", "ndc_label_name": "Aspirin Low Dose Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63739043401", "ndc_label_name": "Aspirin Low Strength Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00574703412", "ndc_label_name": "Aspirin SUPPOSITORY 300 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00574703612", "ndc_label_name": "Aspirin Suppository 600 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536105301", "ndc_label_name": "Aspirin Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536105429", "ndc_label_name": "Aspirin TABLET 325 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000025303", "ndc_label_name": "Aspirin Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536330510", "ndc_label_name": "Aspirin Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536105305", "ndc_label_name": "Aspirin Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16103036511", "ndc_label_name": "Aspirin TABLET 325 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "49483001110", "ndc_label_name": "Aspirin Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904681180", "ndc_label_name": "Aspirin Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51645071601", "ndc_label_name": "Aspirin TABLET 325 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205066887", "ndc_label_name": "Aspirin Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536330501", "ndc_label_name": "Aspirin Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16103036508", "ndc_label_name": "Aspirin TABLET 325 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000025301", "ndc_label_name": "Aspirin Tablet 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000025302", "ndc_label_name": "Aspirin TABLET 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51645071610", "ndc_label_name": "Aspirin TABLET 325 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536100836", "ndc_label_name": "Aspirin TABLET CHEWABLE 81 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16103036605", "ndc_label_name": "Aspirin TABLET CHEWABLE 81 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00603002436", "ndc_label_name": "Aspirin TABLET CHEWABLE 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904404073", "ndc_label_name": "Aspirin TABLET CHEWABLE 81 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16103036611", "ndc_label_name": "Aspirin TABLET CHEWABLE 81 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000017001", "ndc_label_name": "Aspirin Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536100862", "ndc_label_name": "Aspirin Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000042001", "ndc_label_name": "Aspirin Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000042002", "ndc_label_name": "Aspirin Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70000041901", "ndc_label_name": "Aspirin Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536114801", "ndc_label_name": "Aspirin Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904678480", "ndc_label_name": "Aspirin Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483033110", "ndc_label_name": "Aspirin Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000035901", "ndc_label_name": "Aspirin Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904201380", "ndc_label_name": "Aspirin Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904671260", "ndc_label_name": "Aspirin Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16103035708", "ndc_label_name": "Aspirin Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483033101", "ndc_label_name": "Aspirin Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63739052301", "ndc_label_name": "Aspirin Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16103035711", "ndc_label_name": "Aspirin Tablet Delayed Release 325 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536114941", "ndc_label_name": "Aspirin Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16103035609", "ndc_label_name": "Aspirin TABLET DELAYED RELEASE 81 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536100441", "ndc_label_name": "Aspirin Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536100410", "ndc_label_name": "Aspirin Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16103035611", "ndc_label_name": "Aspirin TABLET DELAYED RELEASE 81 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63739052201", "ndc_label_name": "Aspirin Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800003018", "ndc_label_name": "Aspirin Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63739052210", "ndc_label_name": "Aspirin Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70882012230", "ndc_label_name": "Aspirin Tablet Delayed Release 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "42571027460", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62175033035", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884000702", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598033960", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291011660", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714096401", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904705699", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407027160", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162059606", "ndc_label_name": "Aspirin-Dipyridamole ER CAPSULE EXTENDED RELEASE 12 HOUR 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559085060", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462040560", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436009205", "ndc_label_name": "Aspirin-Dipyridamole ER Capsule Extended Release 12 Hour 25-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73457041580", "ndc_label_name": "Aspirin-Omeprazole Tablet Delayed Release 81-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69597034815", "ndc_label_name": "Aspirin-Omeprazole Tablet Delayed Release 81-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71800001430", "ndc_label_name": "Aspirin-Omeprazole Tablet Delayed Release 81-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335062560", "ndc_label_name": "Aspruzyo Sprinkle Packet 1000 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335062460", "ndc_label_name": "Aspruzyo Sprinkle Packet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08373071800", "ndc_label_name": "Assess Full Range Peak Meter Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08373071000", "ndc_label_name": "Assess Full Range Peak Meter Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08373075000", "ndc_label_name": "Assess Low Range Peak Meter Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08373071900", "ndc_label_name": "Assess Low Range Peak Meter Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50486008410", "ndc_label_name": "Assess Peak Flow Meter DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50486008415", "ndc_label_name": "Assess Peak Flow Meter DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317550602", "ndc_label_name": "Assure 3 Control Liquid In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317560006", "ndc_label_name": "Assure 4 Control Level 1 & 2 Liquid In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317560100", "ndc_label_name": "Assure 4 Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317560050", "ndc_label_name": "Assure 4 Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60913000201", "ndc_label_name": "Assure Comfort Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317500005", "ndc_label_name": "Assure Dose Control SOLUTION Normal IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317500006", "ndc_label_name": "Assure Dose Norm/High Control SOLUTION IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317970118", "ndc_label_name": "Assure Haemolance Plus High", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317970125", "ndc_label_name": "Assure Haemolance Plus Low", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317970128", "ndc_label_name": "Assure Haemolance Plus Micro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317970121", "ndc_label_name": "Assure Haemolance Plus Normal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317970112", "ndc_label_name": "Assure Haemolance Plus Ped", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317220602", "ndc_label_name": "Assure II Control Level 1 & 2 Liquid In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317220501", "ndc_label_name": "Assure II Control Liquid In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317980225", "ndc_label_name": "Assure Lance Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317980125", "ndc_label_name": "Assure Lance Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317980128", "ndc_label_name": "Assure Lance Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317980228", "ndc_label_name": "Assure Lance Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317980121", "ndc_label_name": "Assure Lance Lancets 21G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317990125", "ndc_label_name": "Assure Lance Plus Safety 25G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317990130", "ndc_label_name": "Assure Lance Plus Safety 30G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317980328", "ndc_label_name": "Assure Lance Safety Lancet 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38415010029", "ndc_label_name": "Assure Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317500001", "ndc_label_name": "Assure Platinum Meter DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317502030", "ndc_label_name": "Assure Platinum Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317500030", "ndc_label_name": "Assure Platinum Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317500050", "ndc_label_name": "Assure Platinum STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317500100", "ndc_label_name": "Assure Platinum STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317530006", "ndc_label_name": "Assure Prism Control Level 1&2 SOLUTION IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317530001", "ndc_label_name": "Assure Prism multi Meter DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317530101", "ndc_label_name": "Assure Prism multi Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317530050", "ndc_label_name": "Assure Prism multi Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317532050", "ndc_label_name": "Assure Prism multi Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08317460006", "ndc_label_name": "Assure Pro Control Level 1 & 2 Liquid In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00469064773", "ndc_label_name": "Astagraf XL CAPSULE EXTENDED RELEASE 24 HOUR 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00469067773", "ndc_label_name": "Astagraf XL CAPSULE EXTENDED RELEASE 24 HOUR 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00469068773", "ndc_label_name": "Astagraf XL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "08373074200", "ndc_label_name": "AsthmaMentOr Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00186016254", "ndc_label_name": "Atacand HCT Tablet 16-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559065090", "ndc_label_name": "Atacand HCT Tablet 16-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559065190", "ndc_label_name": "Atacand HCT Tablet 32-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337703", "ndc_label_name": "Atacand HCT Tablet 32-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337701", "ndc_label_name": "Atacand HCT Tablet 32-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337704", "ndc_label_name": "Atacand HCT Tablet 32-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186032254", "ndc_label_name": "Atacand HCT Tablet 32-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569580100", "ndc_label_name": "Atacand HCT Tablet 32-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337702", "ndc_label_name": "Atacand HCT Tablet 32-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186032454", "ndc_label_name": "Atacand HCT Tablet 32-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559065290", "ndc_label_name": "Atacand HCT Tablet 32-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337602", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337603", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559064290", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186001654", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569471400", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186001631", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337604", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544021245", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559064230", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544021253", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337601", "ndc_label_name": "Atacand Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186003254", "ndc_label_name": "Atacand Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186003231", "ndc_label_name": "Atacand Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559064390", "ndc_label_name": "Atacand Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559064330", "ndc_label_name": "Atacand Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999098830", "ndc_label_name": "Atacand TABLET 32 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544017745", "ndc_label_name": "Atacand Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186000431", "ndc_label_name": "Atacand Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559064030", "ndc_label_name": "Atacand Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356042730", "ndc_label_name": "Atacand TABLET 8 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186000831", "ndc_label_name": "Atacand Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559064130", "ndc_label_name": "Atacand Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093552606", "ndc_label_name": "Atazanavir Sulfate CAPSULE 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862071160", "ndc_label_name": "Atazanavir Sulfate Capsule 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097044403", "ndc_label_name": "Atazanavir Sulfate Capsule 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714086001", "ndc_label_name": "Atazanavir Sulfate Capsule 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407017160", "ndc_label_name": "Atazanavir Sulfate Capsule 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762040806", "ndc_label_name": "Atazanavir Sulfate Capsule 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407017260", "ndc_label_name": "Atazanavir Sulfate Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093552706", "ndc_label_name": "Atazanavir Sulfate CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714086101", "ndc_label_name": "Atazanavir Sulfate Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862071260", "ndc_label_name": "Atazanavir Sulfate Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762040906", "ndc_label_name": "Atazanavir Sulfate Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097044503", "ndc_label_name": "Atazanavir Sulfate Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762041003", "ndc_label_name": "Atazanavir Sulfate Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093552856", "ndc_label_name": "Atazanavir Sulfate CAPSULE 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097044602", "ndc_label_name": "Atazanavir Sulfate Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687039925", "ndc_label_name": "Atazanavir Sulfate Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714086201", "ndc_label_name": "Atazanavir Sulfate Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904687504", "ndc_label_name": "Atazanavir Sulfate Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407017330", "ndc_label_name": "Atazanavir Sulfate Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862071330", "ndc_label_name": "Atazanavir Sulfate Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687039995", "ndc_label_name": "Atazanavir Sulfate Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00430097903", "ndc_label_name": "Atelvia TABLET DELAYED RELEASE 35 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093075301", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378075710", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781150701", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093075305", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378075701", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003930", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781150710", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717290", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781522901", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999017890", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261051790", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014245", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717230", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742010301", "ndc_label_name": "Atenolol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781522910", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544017190", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544017130", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079068501", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353098660", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063031630", "ndc_label_name": "Atenolol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014218", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289065390", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261051700", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261051760", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090044803", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569365403", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002113806", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999017830", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014250", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760006190", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261051730", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003900", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217023790", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700056730", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569365400", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090044800", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090044805", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862017001", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063031690", "ndc_label_name": "Atenolol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014290", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569365404", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038807", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569365405", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090341005", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090341003", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002992", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353088760", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079068520", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304062301", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038812", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002610", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742010310", "ndc_label_name": "Atenolol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959025830", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788645003", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999017860", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569365406", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980043901", "ndc_label_name": "Atenolol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002960", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919085490", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959025860", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002113803", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788645006", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217023730", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700066130", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116042130", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788976109", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629262601", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002113800", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629262602", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788645009", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864071730", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700066190", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002991", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788707103", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629262604", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289065330", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335054004", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788976103", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002690", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304062310", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788707106", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335054003", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038820", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760064290", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788707109", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629262603", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002930", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919085430", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335054002", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038801", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544033260", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038830", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382002401", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038810", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788904903", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862017099", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788645001", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038815", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788976106", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267002990", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788707101", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980043910", "ndc_label_name": "Atenolol TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335054001", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382002410", "ndc_label_name": "Atenolol TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788976101", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335054005", "ndc_label_name": "Atenolol Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063029701", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014018", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571043011", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093078710", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093078701", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717030", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378021801", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717045", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063095290", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014045", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063029730", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378021810", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781107801", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999045460", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717090", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781522001", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083360", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014090", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063080501", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904539261", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781107810", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090051406", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003730", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781522010", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018100", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063080590", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063080530", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063029790", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544016790", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742010110", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356093030", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356093060", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569388500", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083330", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018190", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999045410", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003700", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760006030", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356093090", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014010", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569388506", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090051400", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864074990", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079075901", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003760", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919027960", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083380", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083345", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289022790", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090341104", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002790", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864074930", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090051405", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304062101", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999045400", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999045490", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700075530", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959046330", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760016390", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544016145", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742010101", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874046814", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090051404", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090051402", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874046890", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002110803", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919025630", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382002210", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079075920", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002110806", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090341105", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079075917", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544024030", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018130", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919027990", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079075963", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959046301", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569388502", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079075919", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569388504", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544024080", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919091471", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187053710", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289022701", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959046360", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874046801", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569388505", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289022730", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205009690", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874046830", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874046820", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002710", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002110800", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544016192", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700056630", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760006090", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629178502", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544024060", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874046860", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760025690", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267003060", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544024092", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919025690", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760043790", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544024045", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788736801", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862016899", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919027930", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304062110", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629178501", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382002201", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874046810", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629178503", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980043701", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874046815", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980043710", "ndc_label_name": "Atenolol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243034709", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862016801", "ndc_label_name": "Atenolol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267003030", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544016160", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544016130", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788736803", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544016180", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788736809", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788736806", "ndc_label_name": "Atenolol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261034900", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717106", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378023110", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093075201", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378023101", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093075210", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717145", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003860", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261034990", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717130", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781522510", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717110", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571043111", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781522501", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781150601", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063006206", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353093960", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717192", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003800", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717160", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014190", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261034930", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261034960", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063006260", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090044208", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544003130", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358003830", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717190", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063076590", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014110", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014118", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083445", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742010201", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544012730", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356073730", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781150610", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083060", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063006230", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063006290", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090304301", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079068401", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544058630", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291014145", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083430", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090304300", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063076530", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353093980", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002100403", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959025340", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544058690", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353093930", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083460", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742010210", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083480", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090044207", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289022801", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53489052910", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083073", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090044200", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353083473", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959025330", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353093945", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090304307", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289022860", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348014230", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090304304", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079068419", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090044201", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217020100", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353093973", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090304308", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760005930", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569343201", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959025320", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079068420", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090044204", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217020130", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569343204", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700024330", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760016490", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569343208", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002100406", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959025300", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079068417", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217020160", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569343207", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700075430", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874033210", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289022803", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217020190", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569343200", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079068463", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002510", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569900900", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700075490", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788645806", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053190", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289022890", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760064390", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002100400", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760005990", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700024360", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919025730", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788761609", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760064330", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053130", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629174003", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700024030", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304062201", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700024390", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919025790", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934014230", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919066430", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760016430", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980043810", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864006501", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629174002", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429002590", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919093530", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864006530", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62584046701", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874033207", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544032615", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62584046711", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874033201", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243030803", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919093590", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629174001", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874033260", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874033215", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68645058554", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243001403", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382002301", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243030809", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187020130", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243001445", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874033290", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874033220", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205022930", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267003130", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788761603", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243030818", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304062210", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68645031054", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980043801", "ndc_label_name": "Atenolol TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874033230", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874033202", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862016901", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243001418", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544032660", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874033214", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116043730", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116023930", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382002310", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243001409", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544032630", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544032645", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788645803", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862016999", "ndc_label_name": "Atenolol TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68645049354", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544032680", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788645809", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267003160", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788761601", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788904803", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544032673", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788645801", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788761606", "ndc_label_name": "Atenolol Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710116801", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 100-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289098830", "ndc_label_name": "Atenolol-Chlorthalidone TABLET 100-25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591578301", "ndc_label_name": "Atenolol-Chlorthalidone TABLET 100-25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378206401", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 100-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629373801", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 100-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714093701", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 100-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378206301", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353014909", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710116701", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261094200", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261094260", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714093601", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591578201", "ndc_label_name": "Atenolol-Chlorthalidone TABLET 50-25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353098509", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629290901", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999051230", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999051290", "ndc_label_name": "Atenolol-Chlorthalidone TABLET 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261094230", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629290902", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289099330", "ndc_label_name": "Atenolol-Chlorthalidone TABLET 50-25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261094290", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629290904", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289099360", "ndc_label_name": "Atenolol-Chlorthalidone TABLET 50-25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289099390", "ndc_label_name": "Atenolol-Chlorthalidone TABLET 50-25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629290903", "ndc_label_name": "Atenolol-Chlorthalidone Tablet 50-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009722401", "ndc_label_name": "Atgam Solution 50 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009722402", "ndc_label_name": "Atgam Solution 50 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "32953009907", "ndc_label_name": "Athletes Foot (Clotrimazole) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00363008002", "ndc_label_name": "Athletes Foot (Terbinafine) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007873", "ndc_label_name": "Athletes Foot (Terbinafine) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00363008001", "ndc_label_name": "Athletes Foot (Terbinafine) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000033801", "ndc_label_name": "Athletes Foot (Terbinafine) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007874", "ndc_label_name": "Athletes Foot (Terbinafine) Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090654300", "ndc_label_name": "Athletes Foot Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000032201", "ndc_label_name": "Athletes Foot Powder Spray Aerosol Powder 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000032101", "ndc_label_name": "Athletes Foot Powder Spray Aerosol Powder 2 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00363034190", "ndc_label_name": "Athletes Foot Powder Spray Aerosol Powder 2 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113015473", "ndc_label_name": "Athletes Foot Spray Aerosol 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00641600010", "ndc_label_name": "Ativan SOLUTION 2 MG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641600101", "ndc_label_name": "Ativan SOLUTION 2 MG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641600001", "ndc_label_name": "Ativan SOLUTION 2 MG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641600125", "ndc_label_name": "Ativan SOLUTION 2 MG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641600301", "ndc_label_name": "Ativan SOLUTION 4 MG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641600201", "ndc_label_name": "Ativan SOLUTION 4 MG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641600325", "ndc_label_name": "Ativan SOLUTION 4 MG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641600210", "ndc_label_name": "Ativan SOLUTION 4 MG/ML INJECTION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187006301", "ndc_label_name": "Ativan TABLET 0.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187006410", "ndc_label_name": "Ativan TABLET 1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267129500", "ndc_label_name": "Ativan TABLET 1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187006401", "ndc_label_name": "Ativan TABLET 1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569092701", "ndc_label_name": "Ativan Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187006501", "ndc_label_name": "Ativan TABLET 2 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35573041530", "ndc_label_name": "Atomoxetine HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407010030", "ndc_label_name": "Atomoxetine HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714075501", "ndc_label_name": "Atomoxetine HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462026530", "ndc_label_name": "Atomoxetine HCl CAPSULE 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093354256", "ndc_label_name": "Atomoxetine HCl CAPSULE 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111051930", "ndc_label_name": "Atomoxetine HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980037303", "ndc_label_name": "Atomoxetine HCl CAPSULE 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505283003", "ndc_label_name": "Atomoxetine HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993004030", "ndc_label_name": "Atomoxetine HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993004630", "ndc_label_name": "Atomoxetine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093354856", "ndc_label_name": "Atomoxetine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35573042130", "ndc_label_name": "Atomoxetine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505283603", "ndc_label_name": "Atomoxetine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714076101", "ndc_label_name": "Atomoxetine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407010630", "ndc_label_name": "Atomoxetine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111056430", "ndc_label_name": "Atomoxetine HCl Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462027130", "ndc_label_name": "Atomoxetine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980037903", "ndc_label_name": "Atomoxetine HCl CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993004130", "ndc_label_name": "Atomoxetine HCl Capsule 18 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714075601", "ndc_label_name": "Atomoxetine HCl Capsule 18 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111052030", "ndc_label_name": "Atomoxetine HCl Capsule 18 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980037403", "ndc_label_name": "Atomoxetine HCl CAPSULE 18 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093354356", "ndc_label_name": "Atomoxetine HCl CAPSULE 18 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462026630", "ndc_label_name": "Atomoxetine HCl CAPSULE 18 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35573041630", "ndc_label_name": "Atomoxetine HCl Capsule 18 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407010130", "ndc_label_name": "Atomoxetine HCl Capsule 18 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505283103", "ndc_label_name": "Atomoxetine HCl Capsule 18 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714075701", "ndc_label_name": "Atomoxetine HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268005711", "ndc_label_name": "Atomoxetine HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093354456", "ndc_label_name": "Atomoxetine HCl CAPSULE 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268005713", "ndc_label_name": "Atomoxetine HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111052830", "ndc_label_name": "Atomoxetine HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407010230", "ndc_label_name": "Atomoxetine HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462026730", "ndc_label_name": "Atomoxetine HCl CAPSULE 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993004230", "ndc_label_name": "Atomoxetine HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505283203", "ndc_label_name": "Atomoxetine HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980037503", "ndc_label_name": "Atomoxetine HCl CAPSULE 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35573041730", "ndc_label_name": "Atomoxetine HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268005813", "ndc_label_name": "Atomoxetine HCl Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268005811", "ndc_label_name": "Atomoxetine HCl Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093354556", "ndc_label_name": "Atomoxetine HCl CAPSULE 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980037603", "ndc_label_name": "Atomoxetine HCl CAPSULE 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714075801", "ndc_label_name": "Atomoxetine HCl Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505283303", "ndc_label_name": "Atomoxetine HCl Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904690804", "ndc_label_name": "Atomoxetine HCl Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687032625", "ndc_label_name": "Atomoxetine HCl CAPSULE 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111052130", "ndc_label_name": "Atomoxetine HCl Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687032695", "ndc_label_name": "Atomoxetine HCl CAPSULE 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462026830", "ndc_label_name": "Atomoxetine HCl CAPSULE 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993004330", "ndc_label_name": "Atomoxetine HCl Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35573041830", "ndc_label_name": "Atomoxetine HCl Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407010330", "ndc_label_name": "Atomoxetine HCl Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35573041930", "ndc_label_name": "Atomoxetine HCl Capsule 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505283403", "ndc_label_name": "Atomoxetine HCl Capsule 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093354656", "ndc_label_name": "Atomoxetine HCl CAPSULE 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714075901", "ndc_label_name": "Atomoxetine HCl Capsule 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993004430", "ndc_label_name": "Atomoxetine HCl Capsule 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407010430", "ndc_label_name": "Atomoxetine HCl Capsule 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111052230", "ndc_label_name": "Atomoxetine HCl Capsule 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462026930", "ndc_label_name": "Atomoxetine HCl CAPSULE 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980037703", "ndc_label_name": "Atomoxetine HCl CAPSULE 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35573042030", "ndc_label_name": "Atomoxetine HCl Capsule 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093354756", "ndc_label_name": "Atomoxetine HCl CAPSULE 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462027030", "ndc_label_name": "Atomoxetine HCl CAPSULE 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714076001", "ndc_label_name": "Atomoxetine HCl Capsule 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407010530", "ndc_label_name": "Atomoxetine HCl Capsule 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980037803", "ndc_label_name": "Atomoxetine HCl CAPSULE 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111056330", "ndc_label_name": "Atomoxetine HCl Capsule 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505283503", "ndc_label_name": "Atomoxetine HCl Capsule 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993004530", "ndc_label_name": "Atomoxetine HCl Capsule 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "46287003001", "ndc_label_name": "Atorvaliq Suspension 20 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395005", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712530", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712560", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729004417", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093505698", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395007", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291014390", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395077", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090125500", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712581", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904629061", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079020801", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395009", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781538192", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571017290", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090125400", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569628200", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712585", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135064910", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111012105", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712590", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087403", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762015501", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090125501", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700047790", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261095900", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087402", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55154663500", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087401", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261095990", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032310", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009315", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760090390", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261095930", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353011545", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760035390", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261095960", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356086090", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505257808", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505257809", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919095690", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356086030", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353011560", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788761809", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356086018", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063047430", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686201", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62175089046", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382024910", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090125401", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407007890", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70882010630", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291014310", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353012060", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686206", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304082790", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382024916", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009311", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62175089043", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934007030", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571017210", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079020820", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097089715", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739001810", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097094415", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762015502", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084009711", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051190", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063037330", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407007810", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645040270", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071091430", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70882011930", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032390", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645048070", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645048054", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700065930", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569628201", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788761801", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686209", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016901", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919095630", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097089705", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788761803", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032377", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111012190", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205024630", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788761806", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016904", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051105", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304082705", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377002713", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610016960", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919054030", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645045854", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016902", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686203", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084009701", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788955603", "ndc_label_name": "Atorvastatin Calcium TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051110", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72205002205", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097094405", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645045870", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335016903", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377002711", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71399061001", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71399051001", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72205002290", "ndc_label_name": "Atorvastatin Calcium Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135065005", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712630", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395107", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395177", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395105", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712690", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395109", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093505998", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097299", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712660", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712685", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781538292", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087501", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904629161", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087503", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712681", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571017310", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097230", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087502", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569628300", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097290", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291014410", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097260", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729004517", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217020990", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356089490", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097200", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111012290", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291014490", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063049630", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356089430", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356089418", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569628301", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571017390", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353085109", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505257908", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009411", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353089245", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762015601", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063049660", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55154663400", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353090409", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353089209", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919091630", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079020920", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090125801", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032477", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018145", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700054830", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217020930", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090125800", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739002010", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919025830", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436998803", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051205", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018160", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032490", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217020960", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407007905", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382025010", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919063230", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079020901", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788633106", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353090445", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505257909", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700054890", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217020999", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645040370", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304082890", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760090430", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645048154", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353090460", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304082805", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762015602", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645059154", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788968303", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645048170", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919025890", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788634101", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090125700", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645045954", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760035490", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788634106", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335000403", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788634109", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051210", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377002813", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090125701", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788633101", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62175089143", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011645", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610018045", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097094512", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084009801", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377002811", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009415", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70882012030", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645045970", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934006930", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407007990", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71399052005", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084009811", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610011660", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111012205", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645048254", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032410", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382025016", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62175089146", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788633103", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051290", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788633109", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071091530", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610002245", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788634103", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097089812", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097089805", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610002260", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70882010230", "ndc_label_name": "Atorvastatin Calcium TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097094505", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72205002305", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205024730", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335000401", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71399062005", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610018060", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72205002390", "ndc_label_name": "Atorvastatin Calcium Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395207", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712730", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712760", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093505898", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395209", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087603", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395277", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712781", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904629261", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712785", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291014590", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395205", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712790", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729004617", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087601", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087602", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097360", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571017490", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353028045", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097390", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781538492", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097300", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018260", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356092930", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082645", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353087345", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082115", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291014550", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135065110", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353028715", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353028730", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018215", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090126000", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353095930", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407008010", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571017410", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097330", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082145", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353028760", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018245", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032590", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55154664600", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111012390", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018230", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063045330", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353095945", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082130", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082160", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760070930", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919030390", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58517000130", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353028015", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353028745", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090126101", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082660", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353087330", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377002913", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304082905", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505258008", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353087315", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082615", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009515", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090126001", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009511", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335010204", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304082990", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760090530", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353095915", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458088116", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051305", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090126100", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436998901", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610016815", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739003610", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62175089241", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090343801", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762015701", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051310", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090343800", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079021020", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505258009", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084009901", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62175089246", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097089915", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051390", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645041754", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079021001", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458088110", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645059254", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382025110", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084009911", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934009130", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788683609", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097094615", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407008090", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569628401", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70882010930", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645056854", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382025116", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335076701", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610016860", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335010201", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569628400", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762015702", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72205002405", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788683601", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71399064001", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610016315", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72205002490", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610016330", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111012305", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032505", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610016845", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788683603", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032577", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610016345", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645046054", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788683606", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335010202", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760035530", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71399054001", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097089905", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610016830", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097094605", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760090590", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377002911", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919030330", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205026490", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071091630", "ndc_label_name": "Atorvastatin Calcium TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335010203", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645048354", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335076703", "ndc_label_name": "Atorvastatin Calcium Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018445", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395305", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781538892", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093505798", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712860", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00179014145", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395307", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904629304", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018460", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395377", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087701", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378395309", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712881", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135065305", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712830", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087703", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353084330", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571017510", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291014690", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712885", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714087702", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082753", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440712890", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729004716", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55154438406", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353032145", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353081530", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571017590", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261099530", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082760", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353032115", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261099590", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919053130", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353084360", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353081545", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353032160", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261099560", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353084345", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353081579", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018415", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62175089741", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217031930", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090126400", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353081560", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291014650", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353098315", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353098115", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018430", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187065690", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217031990", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762015801", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353084315", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353032130", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090126501", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353098145", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353081515", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084059095", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032605", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762015802", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353098130", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082745", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407008190", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353098160", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082715", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788899109", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032690", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304083005", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353098345", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090126401", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187090790", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353098330", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353082730", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097091105", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267108", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739003733", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079021103", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090126500", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304083090", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407008105", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009611", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097091112", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505267109", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382025210", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569628501", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268009612", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205033590", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569628500", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111012405", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097094712", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610003615", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645041854", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111012490", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788694003", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335058302", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645049554", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429032633", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335029501", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009430", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788694001", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700003430", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610003630", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610017060", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788899106", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919053190", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610003660", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610017030", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788899101", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62175089746", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610017045", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051405", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335029503", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084059025", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72205002590", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877051490", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377003014", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382025216", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335058303", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645046154", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009445", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205009890", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788694006", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335029502", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788694009", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335058301", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788899103", "ndc_label_name": "Atorvastatin Calcium TABLET 80 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71399068005", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097094705", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610003645", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377003012", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610017015", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009415", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009460", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72205002505", "ndc_label_name": "Atorvastatin Calcium Tablet 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66689006218", "ndc_label_name": "Atovaquone Suspension 750 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993006272", "ndc_label_name": "Atovaquone Suspension 750 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162069388", "ndc_label_name": "Atovaquone SUSPENSION 750 MG/5ML ORAL", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714090001", "ndc_label_name": "Atovaquone Suspension 750 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10702022321", "ndc_label_name": "Atovaquone Suspension 750 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180028201", "ndc_label_name": "Atovaquone Suspension 750 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722062921", "ndc_label_name": "Atovaquone Suspension 750 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66689006242", "ndc_label_name": "Atovaquone Suspension 750 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462042121", "ndc_label_name": "Atovaquone Suspension 750 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440704001", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090298004", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378416201", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 250-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063052207", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063039320", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 250-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063052224", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544090910", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063039314", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 250-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440704065", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633003", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130203", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130202", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063052214", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130208", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063052220", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063052268", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544090905", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187087924", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130206", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130204", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130200", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633008", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130201", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063052269", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261090001", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462040467", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 250-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090298000", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993006027", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130205", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001024515", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 250-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130207", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063052273", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130209", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462040401", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 250-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090298002", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001024500", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 250-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090298003", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090298008", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090298006", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633000", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090298001", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633005", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090298005", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760049804", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090298009", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090298007", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633002", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760049813", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633004", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633001", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633007", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462040444", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633009", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569633006", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118040402", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 250-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760049811", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993006002", "ndc_label_name": "Atovaquone-Proguanil HCl Tablet 250-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001024514", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 250-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378416001", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 62.5-25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462040201", "ndc_label_name": "Atovaquone-Proguanil HCl TABLET 62.5-25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13548007045", "ndc_label_name": "Atralin GEL 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118999604", "ndc_label_name": "Atralin GEL 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436010101", "ndc_label_name": "Atripla Tablet 600-200-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090098000", "ndc_label_name": "Atripla Tablet 600-200-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "15584010101", "ndc_label_name": "Atripla Tablet 600-200-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00517040125", "ndc_label_name": "Atropine Sulfate (PF) Solution 0.4 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517101025", "ndc_label_name": "Atropine Sulfate (PF) Solution 1 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090452400", "ndc_label_name": "Atropine Sulfate (PF) Solution 1 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517040125", "ndc_label_name": "Atropine Sulfate Solution 0.4 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517100425", "ndc_label_name": "Atropine Sulfate Solution 0.4 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729052563", "ndc_label_name": "Atropine Sulfate Solution 0.4 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517100401", "ndc_label_name": "Atropine Sulfate Solution 0.4 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729052508", "ndc_label_name": "Atropine Sulfate Solution 0.4 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069063125", "ndc_label_name": "Atropine Sulfate Solution 0.4 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505622600", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00065081702", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069058201", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090310400", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00065081701", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478021502", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069071601", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090700000", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76478001502", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090731300", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70756065225", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069058101", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478021515", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478021505", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603026402", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60219174903", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090629500", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60219174802", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76478001505", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505622601", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60219175008", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70756065125", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76478001515", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505622602", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603026401", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70756065335", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82260000101", "ndc_label_name": "Atropine Sulfate Solution 1 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517101025", "ndc_label_name": "Atropine Sulfate Solution 1 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517100101", "ndc_label_name": "Atropine Sulfate Solution 1 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729052608", "ndc_label_name": "Atropine Sulfate Solution 1 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517100125", "ndc_label_name": "Atropine Sulfate Solution 1 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069064125", "ndc_label_name": "Atropine Sulfate Solution 1 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729052663", "ndc_label_name": "Atropine Sulfate Solution 1 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641625101", "ndc_label_name": "Atropine Sulfate Solution 8 MG/20ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641625110", "ndc_label_name": "Atropine Sulfate Solution 8 MG/20ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729051205", "ndc_label_name": "Atropine Sulfate Solution 8 MG/20ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641600601", "ndc_label_name": "Atropine Sulfate Solution 8 MG/20ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729051243", "ndc_label_name": "Atropine Sulfate Solution 8 MG/20ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641600610", "ndc_label_name": "Atropine Sulfate Solution 8 MG/20ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323058003", "ndc_label_name": "Atropine Sulfate Solution 8 MG/20ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323058020", "ndc_label_name": "Atropine Sulfate Solution 8 MG/20ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729048303", "ndc_label_name": "Atropine Sulfate Solution Prefilled Syringe 0.25 MG/5ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409963005", "ndc_label_name": "Atropine Sulfate Solution Prefilled Syringe 0.25 MG/5ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409963015", "ndc_label_name": "Atropine Sulfate Solution Prefilled Syringe 0.25 MG/5ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409491011", "ndc_label_name": "Atropine Sulfate Solution Prefilled Syringe 0.5 MG/5ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729048490", "ndc_label_name": "Atropine Sulfate Solution Prefilled Syringe 0.5 MG/5ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409491034", "ndc_label_name": "Atropine Sulfate Solution Prefilled Syringe 0.5 MG/5ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70121170507", "ndc_label_name": "Atropine Sulfate Solution Prefilled Syringe 0.5 MG/5ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70121170501", "ndc_label_name": "Atropine Sulfate Solution Prefilled Syringe 0.5 MG/5ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00597008717", "ndc_label_name": "Atrovent HFA Aerosol Solution 17 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569575700", "ndc_label_name": "Atrovent HFA Aerosol Solution 17 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090096100", "ndc_label_name": "Atrovent HFA Aerosol Solution 17 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58468021002", "ndc_label_name": "Aubagio Tablet 14 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58468021001", "ndc_label_name": "Aubagio Tablet 14 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58468021004", "ndc_label_name": "Aubagio Tablet 14 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58468021104", "ndc_label_name": "Aubagio Tablet 7 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58468021102", "ndc_label_name": "Aubagio Tablet 7 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58468021101", "ndc_label_name": "Aubagio Tablet 7 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50102022021", "ndc_label_name": "Aubra EQ Tablet 0.1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102022023", "ndc_label_name": "Aubra EQ Tablet 0.1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102012001", "ndc_label_name": "Aubra Tablet 0.1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102012003", "ndc_label_name": "Aubra Tablet 0.1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102012010", "ndc_label_name": "Aubra Tablet 0.1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102012048", "ndc_label_name": "Aubra Tablet 0.1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598000351", "ndc_label_name": "Augmentin ES-600 Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598000354", "ndc_label_name": "Augmentin ES-600 Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "81964000354", "ndc_label_name": "Augmentin ES-600 Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598000369", "ndc_label_name": "Augmentin ES-600 Suspension Reconstituted 600-42.9 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598001253", "ndc_label_name": "Augmentin Suspension Reconstituted 125-31.25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569013700", "ndc_label_name": "Augmentin Suspension Reconstituted 125-31.25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868019902", "ndc_label_name": "Augmentin SUSPENSION RECONSTITUTED 125-31.25 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598001251", "ndc_label_name": "Augmentin Suspension Reconstituted 125-31.25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72508001201", "ndc_label_name": "Augmentin Suspension Reconstituted 125-31.25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868019903", "ndc_label_name": "Augmentin SUSPENSION RECONSTITUTED 125-31.25 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598001252", "ndc_label_name": "Augmentin Suspension Reconstituted 125-31.25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72508001205", "ndc_label_name": "Augmentin Suspension Reconstituted 125-31.25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868019900", "ndc_label_name": "Augmentin SUSPENSION RECONSTITUTED 125-31.25 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72508001203", "ndc_label_name": "Augmentin Suspension Reconstituted 125-31.25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00247002714", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00029608031", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00247002720", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002121", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00247002704", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598000614", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00029608012", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00247002715", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002120", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002115", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00247002721", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002130", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00247002709", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868038801", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999021320", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116024030", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569195904", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57866605102", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002104", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959002114", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569195901", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58016480801", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569195906", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868038800", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868038804", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868038802", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55045125807", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57866605103", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289029615", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864074030", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289029630", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68115099120", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57866605101", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57866605104", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116068130", "ndc_label_name": "Augmentin Tablet 500-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267044415", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267099220", "ndc_label_name": "Augmentin TABLET 500-125 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00003416060", "ndc_label_name": "Augtyro Capsule 160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00003416014", "ndc_label_name": "Augtyro Capsule 160 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00003404012", "ndc_label_name": "Augtyro Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00003404060", "ndc_label_name": "Augtyro Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08214065724", "ndc_label_name": "Aurora Lancet Super Thin 30G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08214015724", "ndc_label_name": "Aurora Lancet Thin 23G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65862093521", "ndc_label_name": "Aurovela 1.5/30 Tablet 1.5-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862093574", "ndc_label_name": "Aurovela 1.5/30 Tablet 1.5-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862093988", "ndc_label_name": "Aurovela 1/20 Tablet 1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862093921", "ndc_label_name": "Aurovela 1/20 Tablet 1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862093488", "ndc_label_name": "Aurovela 24 FE Tablet 1-20 MG-MCG(24) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862093487", "ndc_label_name": "Aurovela 24 FE Tablet 1-20 MG-MCG(24) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862094188", "ndc_label_name": "Aurovela Fe 1.5/30 Tablet 1.5-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862094187", "ndc_label_name": "Aurovela Fe 1.5/30 Tablet 1.5-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862094088", "ndc_label_name": "Aurovela FE 1/20 Tablet 1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862094087", "ndc_label_name": "Aurovela FE 1/20 Tablet 1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59922063101", "ndc_label_name": "Auryxia TABLET 1 GM 210 MG(Fe) ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68546017260", "ndc_label_name": "Austedo TABLET 12 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68546017060", "ndc_label_name": "Austedo TABLET 6 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68546017160", "ndc_label_name": "Austedo TABLET 9 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68546047729", "ndc_label_name": "Austedo XR Patient Titration Tablet Extended Release Therapy Pack 12 & 18 & 24 & 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68546049052", "ndc_label_name": "Austedo XR Patient Titration Tablet Extended Release Therapy Pack 6 & 12 & 24 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68546047156", "ndc_label_name": "Austedo XR Tablet Extended Release 24 Hour 12 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68546047956", "ndc_label_name": "Austedo XR Tablet Extended Release 24 Hour 18 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68546047256", "ndc_label_name": "Austedo XR Tablet Extended Release 24 Hour 24 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68546047356", "ndc_label_name": "Austedo XR Tablet Extended Release 24 Hour 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68546047456", "ndc_label_name": "Austedo XR Tablet Extended Release 24 Hour 36 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68546047556", "ndc_label_name": "Austedo XR Tablet Extended Release 24 Hour 42 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68546047656", "ndc_label_name": "Austedo XR Tablet Extended Release 24 Hour 48 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68546047056", "ndc_label_name": "Austedo XR Tablet Extended Release 24 Hour 6 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "25294000616", "ndc_label_name": "Auto-Lancet", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "25294000602", "ndc_label_name": "Auto-Lancet", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "25294000601", "ndc_label_name": "Auto-Lancet", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "25294000100", "ndc_label_name": "Auto-Lancet Mini", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "25294000600", "ndc_label_name": "Auto-Lancet Mini", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "25294000603", "ndc_label_name": "Auto-Lancet Mini", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "25294000624", "ndc_label_name": "Auto-Lancet Mini", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08214027001", "ndc_label_name": "Autolet Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08470027101", "ndc_label_name": "Autolet Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08470027001", "ndc_label_name": "Autolet Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08214027101", "ndc_label_name": "Autolet Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68016016201", "ndc_label_name": "Autolet Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08214026501", "ndc_label_name": "Autolet Mini", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08214026001", "ndc_label_name": "Autolet Mini", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08470026001", "ndc_label_name": "Autolet Mini", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08470026501", "ndc_label_name": "Autolet Mini", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08214027501", "ndc_label_name": "Autolet Plus", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08470027401", "ndc_label_name": "Autolet Plus", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08470027601", "ndc_label_name": "Autolet Plus", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "81968004530", "ndc_label_name": "Auvelity Tablet Extended Release 45-105 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "81968004560", "ndc_label_name": "Auvelity Tablet Extended Release 45-105 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60842002102", "ndc_label_name": "Auvi-Q Solution Auto-Injector 0.1 MG/0.1ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60842002101", "ndc_label_name": "Auvi-Q Solution Auto-Injector 0.1 MG/0.1ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60842002201", "ndc_label_name": "Auvi-Q Solution Auto-Injector 0.15 MG/0.15ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60842002202", "ndc_label_name": "Auvi-Q Solution Auto-Injector 0.15 MG/0.15ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60842002301", "ndc_label_name": "Auvi-Q Solution Auto-Injector 0.3 MG/0.3ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60842002302", "ndc_label_name": "Auvi-Q Solution Auto-Injector 0.3 MG/0.3ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00024585530", "ndc_label_name": "Avalide TABLET 150-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024585590", "ndc_label_name": "Avalide Tablet 150-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356037415", "ndc_label_name": "Avalide TABLET 150-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356037430", "ndc_label_name": "Avalide TABLET 150-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024585690", "ndc_label_name": "Avalide Tablet 300-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024585630", "ndc_label_name": "Avalide TABLET 300-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356040630", "ndc_label_name": "Avalide TABLET 300-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569457200", "ndc_label_name": "Avapro Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864072630", "ndc_label_name": "Avapro Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356085430", "ndc_label_name": "Avapro TABLET 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864072615", "ndc_label_name": "Avapro Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337303", "ndc_label_name": "Avapro Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337301", "ndc_label_name": "Avapro Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024585130", "ndc_label_name": "Avapro TABLET 150 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105050315", "ndc_label_name": "Avapro TABLET 150 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105050309", "ndc_label_name": "Avapro TABLET 150 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337302", "ndc_label_name": "Avapro Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105050301", "ndc_label_name": "Avapro TABLET 150 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629337304", "ndc_label_name": "Avapro Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105050306", "ndc_label_name": "Avapro TABLET 150 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105050303", "ndc_label_name": "Avapro TABLET 150 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105050409", "ndc_label_name": "Avapro TABLET 300 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105050406", "ndc_label_name": "Avapro TABLET 300 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024585230", "ndc_label_name": "Avapro TABLET 300 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864077115", "ndc_label_name": "Avapro Tablet 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024585290", "ndc_label_name": "Avapro Tablet 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544040045", "ndc_label_name": "Avapro Tablet 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105050403", "ndc_label_name": "Avapro TABLET 300 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105050401", "ndc_label_name": "Avapro TABLET 300 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105050415", "ndc_label_name": "Avapro TABLET 300 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569586700", "ndc_label_name": "Avapro Tablet 75 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00024585090", "ndc_label_name": "Avapro TABLET 75 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00178048008", "ndc_label_name": "Avar Cleanser Liquid 10-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49769052645", "ndc_label_name": "Avar-e Emollient CREAM 10-5 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00178047045", "ndc_label_name": "Avar-e Emollient CREAM 10-5 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23589002745", "ndc_label_name": "Avar-e Emollient CREAM 10-5 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00178047002", "ndc_label_name": "Avar-e Emollient CREAM 10-5 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00178046002", "ndc_label_name": "Avar-e Green Cream 10-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00178046045", "ndc_label_name": "Avar-e Green CREAM 10-5 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23589002845", "ndc_label_name": "Avar-e Green CREAM 10-5 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49769052745", "ndc_label_name": "Avar-e Green CREAM 10-5 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242006010", "ndc_label_name": "Avastin Solution 100 MG/4ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50242006001", "ndc_label_name": "Avastin SOLUTION 100 MG/4ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50242006101", "ndc_label_name": "Avastin SOLUTION 400 MG/16ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50242006110", "ndc_label_name": "Avastin Solution 400 MG/16ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00037663104", "ndc_label_name": "AVC Vaginal Cream 15 % Vaginal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67979051143", "ndc_label_name": "Aveed SOLUTION 750 MG/3ML Intramuscular", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555904579", "ndc_label_name": "Aviane TABLET 0.1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555904558", "ndc_label_name": "Aviane TABLET 0.1-20 MG-MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187088928", "ndc_label_name": "Aviane TABLET 0.1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378614144", "ndc_label_name": "Avita Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378614145", "ndc_label_name": "Avita Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378614044", "ndc_label_name": "Avita Gel 0.025 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378614045", "ndc_label_name": "Avita Gel 0.025 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00173071215", "ndc_label_name": "Avodart Capsule 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173071204", "ndc_label_name": "Avodart Capsule 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105098703", "ndc_label_name": "Avodart CAPSULE 0.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569660700", "ndc_label_name": "Avodart Capsule 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59627033304", "ndc_label_name": "Avonex Pen Auto-injector Kit 30 MCG/0.5ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59627022205", "ndc_label_name": "Avonex Prefilled Prefilled Syringe Kit 30 MCG/0.5ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55513067001", "ndc_label_name": "Avsola Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51285042410", "ndc_label_name": "Aygestin Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569342500", "ndc_label_name": "Ayr Solution 0.65 % Nasal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00225038080", "ndc_label_name": "Ayr SOLUTION 0.65 % NASAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "65862084828", "ndc_label_name": "Ayuna Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862084888", "ndc_label_name": "Ayuna Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72064011030", "ndc_label_name": "Ayvakit Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72064012030", "ndc_label_name": "Ayvakit Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72064012530", "ndc_label_name": "Ayvakit Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72064013030", "ndc_label_name": "Ayvakit Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72064015030", "ndc_label_name": "Ayvakit Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781325394", "ndc_label_name": "AzaCITIDine SUSPENSION RECONSTITUTED 100 MG INJECTION", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781925394", "ndc_label_name": "AzaCITIDine Suspension Reconstituted 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485020101", "ndc_label_name": "AzaCITIDine Suspension Reconstituted 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729030610", "ndc_label_name": "AzaCITIDine Suspension Reconstituted 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591289749", "ndc_label_name": "AzaCITIDine Suspension Reconstituted 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323077139", "ndc_label_name": "AzaCITIDine SUSPENSION RECONSTITUTED 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13925052301", "ndc_label_name": "AzaCITIDine SUSPENSION RECONSTITUTED 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598046562", "ndc_label_name": "AzaCITIDine SUSPENSION RECONSTITUTED 100 MG INJECTION", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598067811", "ndc_label_name": "AzaCITIDine SUSPENSION RECONSTITUTED 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714092701", "ndc_label_name": "azaCITIDine Suspension Reconstituted 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457025430", "ndc_label_name": "azaCITIDine Suspension Reconstituted 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598030562", "ndc_label_name": "AzaCITIDine SUSPENSION RECONSTITUTED 100 MG INJECTION", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679009602", "ndc_label_name": "azaCITIDine Suspension Reconstituted 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679009601", "ndc_label_name": "azaCITIDine Suspension Reconstituted 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097080540", "ndc_label_name": "azaCITIDine Suspension Reconstituted 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51991079798", "ndc_label_name": "azaCITIDine Suspension Reconstituted 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001031356", "ndc_label_name": "AzaCITIDine SUSPENSION RECONSTITUTED 100 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65649024141", "ndc_label_name": "Azasan Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65649023141", "ndc_label_name": "Azasan Tablet 75 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82584030703", "ndc_label_name": "AzaSite Solution 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478030703", "ndc_label_name": "AzaSite SOLUTION 1 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143956601", "ndc_label_name": "AzaTHIOprine Sodium SOLUTION RECONSTITUTED 100 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291006301", "ndc_label_name": "azaTHIOprine Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682024101", "ndc_label_name": "azaTHIOprine Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60219203701", "ndc_label_name": "azaTHIOprine Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382012001", "ndc_label_name": "azaTHIOprine Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079062001", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407018201", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378100501", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054408425", "ndc_label_name": "AzaTHIOprine TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261075890", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261075830", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382000305", "ndc_label_name": "AzaTHIOprine TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261075800", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079062006", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238107601", "ndc_label_name": "AzaTHIOprine TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261075860", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084022901", "ndc_label_name": "AzaTHIOprine TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353074560", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353068609", "ndc_label_name": "AzaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353074509", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462050201", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610012409", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353068660", "ndc_label_name": "AzaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60219107601", "ndc_label_name": "AzaTHIOprine TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610030660", "ndc_label_name": "azaTHIOprine Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382000301", "ndc_label_name": "AzaTHIOprine TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084022911", "ndc_label_name": "AzaTHIOprine TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60219203601", "ndc_label_name": "azaTHIOprine Tablet 75 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682023101", "ndc_label_name": "azaTHIOprine Tablet 75 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382011901", "ndc_label_name": "azaTHIOprine Tablet 75 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71258001502", "ndc_label_name": "Azedra Dosimetric Solution 15 MCI/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71258001522", "ndc_label_name": "Azedra Therapeutic Solution 15 MCI/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672138903", "ndc_label_name": "Azelaic Acid Gel 15 % External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591213155", "ndc_label_name": "Azelaic Acid Gel 15 % External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115162456", "ndc_label_name": "Azelaic Acid Gel 15 % External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "21922003814", "ndc_label_name": "Azelaic Acid Gel 15 % External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462062652", "ndc_label_name": "Azelaic Acid Gel 15 % External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781717250", "ndc_label_name": "Azelaic Acid Gel 15 % External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162229702", "ndc_label_name": "Azelaic Acid Gel 15 % External", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332050606", "ndc_label_name": "Azelastine HCl Solution 0.05 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505057804", "ndc_label_name": "Azelastine HCl SOLUTION 0.05 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069009101", "ndc_label_name": "Azelastine HCl Solution 0.05 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314030802", "ndc_label_name": "Azelastine HCl SOLUTION 0.05 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478071810", "ndc_label_name": "Azelastine HCl Solution 0.05 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72266014101", "ndc_label_name": "Azelastine HCl Solution 0.05 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335093890", "ndc_label_name": "Azelastine HCl SOLUTION 0.05 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090253800", "ndc_label_name": "Azelastine HCl Solution 0.1 % Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291015330", "ndc_label_name": "Azelastine HCl Solution 0.1 % Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51525029403", "ndc_label_name": "Azelastine HCl Solution 0.1 % Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335077991", "ndc_label_name": "Azelastine HCl SOLUTION 0.1 % NASAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054029399", "ndc_label_name": "Azelastine HCl Solution 0.1 % Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991081403", "ndc_label_name": "Azelastine HCl Solution 0.1 % Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505083305", "ndc_label_name": "Azelastine HCl SOLUTION 0.1 % NASAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090233000", "ndc_label_name": "Azelastine HCl Solution 0.1 % Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569664300", "ndc_label_name": "Azelastine HCl Solution 0.1 % Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802002683", "ndc_label_name": "Azelastine HCl Solution 0.15 % Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162070684", "ndc_label_name": "Azelastine HCl Solution 0.15 % Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59651021530", "ndc_label_name": "Azelastine HCl Solution 0.15 % Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505084805", "ndc_label_name": "Azelastine HCl Solution 0.15 % Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51525023403", "ndc_label_name": "Azelastine HCl Solution 0.15 % Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50383094230", "ndc_label_name": "Azelastine HCl Solution 0.15 % Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629251901", "ndc_label_name": "Azelastine HCl Solution 0.15 % Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162067684", "ndc_label_name": "Azelastine HCl SOLUTION 137 MCG/SPRAY Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67877047750", "ndc_label_name": "Azelastine HCl SOLUTION 137 MCG/SPRAY Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72162212702", "ndc_label_name": "Azelastine-Fluticasone Suspension 137-50 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505095303", "ndc_label_name": "Azelastine-Fluticasone Suspension 137-50 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378345823", "ndc_label_name": "Azelastine-Fluticasone Suspension 137-50 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629861201", "ndc_label_name": "Azelastine-Fluticasone Suspension 137-50 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802006601", "ndc_label_name": "Azelastine-Fluticasone Suspension 137-50 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72162138802", "ndc_label_name": "Azelastine-Fluticasone Suspension 137-50 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68546014256", "ndc_label_name": "Azilect TABLET 0.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353001518", "ndc_label_name": "Azilect Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68546022956", "ndc_label_name": "Azilect TABLET 1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356048701", "ndc_label_name": "Azithromycin Packet 1 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569580600", "ndc_label_name": "Azithromycin Packet 1 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762305102", "ndc_label_name": "Azithromycin Packet 1 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762305101", "ndc_label_name": "Azithromycin Packet 1 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409014421", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457086000", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021018066", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409014410", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70095002501", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70436001982", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756051240", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150017410", "ndc_label_name": "Azithromycin SOLUTION RECONSTITUTED 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860012541", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70095002502", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323039812", "ndc_label_name": "Azithromycin SOLUTION RECONSTITUTED 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409014411", "ndc_label_name": "Azithromycin SOLUTION RECONSTITUTED 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323039814", "ndc_label_name": "Azithromycin SOLUTION RECONSTITUTED 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860010010", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860010041", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860012566", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756051244", "ndc_label_name": "Azithromycin SOLUTION RECONSTITUTED 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323039810", "ndc_label_name": "Azithromycin SOLUTION RECONSTITUTED 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457086050", "ndc_label_name": "Azithromycin Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43386047060", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090186800", "ndc_label_name": "Azithromycin Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569580700", "ndc_label_name": "Azithromycin Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090249100", "ndc_label_name": "Azithromycin Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710145701", "ndc_label_name": "Azithromycin Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356004415", "ndc_label_name": "Azithromycin Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806014731", "ndc_label_name": "Azithromycin Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093202723", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071152705", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651000715", "ndc_label_name": "Azithromycin Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261073601", "ndc_label_name": "Azithromycin Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762311001", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356019915", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261091901", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356019930", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093202623", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090183500", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806015033", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093202631", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569580800", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569580900", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806015134", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43386047161", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261047201", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071152805", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090098300", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093202694", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569886700", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569581000", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762313001", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090250900", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806014932", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205021630", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959093215", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959093230", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762312001", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700073130", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700021130", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919038230", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090098400", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700078415", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651000830", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788995903", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788904603", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762314001", "ndc_label_name": "Azithromycin SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651000815", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710145802", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651000823", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710145902", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710146002", "ndc_label_name": "Azithromycin Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781149631", "ndc_label_name": "Azithromycin TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781577631", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781149668", "ndc_label_name": "Azithromycin TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093714656", "ndc_label_name": "Azithromycin TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717506", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717504", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440717502", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781808926", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904670861", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063009004", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090095800", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904670806", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781577626", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781149669", "ndc_label_name": "Azithromycin TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781808931", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904640561", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013918", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063057202", "ndc_label_name": "Azithromycin TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090178800", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353069306", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063009002", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781577606", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013910", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090321300", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261013930", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063057204", "ndc_label_name": "Azithromycin TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268009815", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090338501", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063052404", "ndc_label_name": "Azithromycin TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781577669", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358004006", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50111078751", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063072804", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700043206", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224002206", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436435601", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353082206", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904640506", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50111078710", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268010315", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353069387", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700078506", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569575500", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002222404", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436149601", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063072802", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50111078766", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224002230", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090178801", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762219801", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762306003", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002222806", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217017301", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090338500", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268009811", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289096414", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700043266", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687028211", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505258100", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569575501", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569885500", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268010311", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436078701", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762306001", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118078706", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105067005", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505258103", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700035106", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289096404", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436435701", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224002218", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919055506", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762306002", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205015806", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629267301", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505258102", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700006506", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959083806", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217016001", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739057510", "ndc_label_name": "Azithromycin TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919036206", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610000130", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862064163", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505258105", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700070506", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700020606", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217026301", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874119706", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187016906", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687028201", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70882010706", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919017006", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762219807", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187000706", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569575400", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862064130", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187060406", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187028406", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569575401", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679096105", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687028265", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071132306", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762219803", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105067018", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679096101", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180016006", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862064169", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105067003", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071039204", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180016011", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105067006", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084027801", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679096104", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180016013", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788893906", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788706606", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105067001", "ndc_label_name": "Azithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788952906", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788907702", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788997706", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084027811", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452017104", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205002106", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452017113", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452017173", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205011904", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205015866", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610000187", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69677012906", "ndc_label_name": "Azithromycin TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610038106", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610000106", "ndc_label_name": "Azithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090193900", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358004110", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781578931", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054002", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261087901", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781194133", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781194131", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093716956", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959092703", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054007", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063050603", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054005", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063050679", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781809003", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090193901", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781578903", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762307001", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056803", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056879", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090233401", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054003", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356079803", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090233500", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356001703", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762307002", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063071303", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090096000", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50111078855", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054079", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063071302", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268009913", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063050602", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063056802", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063071379", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50111078810", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687027121", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063071305", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268010413", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268010411", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063050607", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063071307", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090165500", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224012209", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105065301", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090233400", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569620401", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002004703", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50111078867", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224012203", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090165501", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224012230", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084027911", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569835500", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027402", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569620400", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268009911", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700083203", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090240700", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217016101", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180016106", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505258200", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862064230", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788708205", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027403", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505258205", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679096405", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569575600", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788708203", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679096401", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862064264", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788907803", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505258203", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071077405", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105065319", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289027407", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70882011803", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788894703", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862064290", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205019603", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919077603", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70882010803", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084027921", "ndc_label_name": "Azithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687027111", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679096403", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72189001502", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105065305", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788952103", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105065303", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452017213", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180016111", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105065306", "ndc_label_name": "Azithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180016113", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788894705", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452017272", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452017274", "ndc_label_name": "Azithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093714756", "ndc_label_name": "Azithromycin Tablet 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781149731", "ndc_label_name": "Azithromycin TABLET 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569580400", "ndc_label_name": "Azithromycin Tablet 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679096201", "ndc_label_name": "Azithromycin Tablet 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687031495", "ndc_label_name": "Azithromycin Tablet 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50111078910", "ndc_label_name": "Azithromycin TABLET 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762308001", "ndc_label_name": "Azithromycin Tablet 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781579331", "ndc_label_name": "Azithromycin Tablet 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224022230", "ndc_label_name": "Azithromycin Tablet 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452017313", "ndc_label_name": "Azithromycin Tablet 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687031425", "ndc_label_name": "Azithromycin Tablet 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180016206", "ndc_label_name": "Azithromycin Tablet 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084092032", "ndc_label_name": "Azithromycin TABLET 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084092033", "ndc_label_name": "Azithromycin TABLET 600 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338005501", "ndc_label_name": "Azmiro Solution Prefilled Syringe 200 MG/ML Intramuscular", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58980081960", "ndc_label_name": "Azolen Anti-Fungal Wash Solution 2 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58980081860", "ndc_label_name": "Azolen Anti-Fungal Wash Solution 2 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00065027510", "ndc_label_name": "Azopt Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569636800", "ndc_label_name": "Azopt Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00065027515", "ndc_label_name": "Azopt Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65597011130", "ndc_label_name": "Azor Tablet 10-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597011330", "ndc_label_name": "Azor Tablet 10-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597011030", "ndc_label_name": "Azor Tablet 5-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597011090", "ndc_label_name": "Azor TABLET 5-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597011230", "ndc_label_name": "Azor Tablet 5-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65038028699", "ndc_label_name": "Azstarys Capsule 26.1-5.2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65038042999", "ndc_label_name": "Azstarys Capsule 39.2-7.8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65038056199", "ndc_label_name": "Azstarys Capsule 52.3-10.4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00013010220", "ndc_label_name": "Azulfidine EN-tabs Tablet Delayed Release 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00013010201", "ndc_label_name": "Azulfidine EN-tabs Tablet Delayed Release 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00013010120", "ndc_label_name": "Azulfidine Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00013010110", "ndc_label_name": "Azulfidine Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00013010101", "ndc_label_name": "Azulfidine Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862007206", "ndc_label_name": "Azurette Tablet 0.15-0.02/0.01 MG (21/5) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862007201", "ndc_label_name": "Azurette Tablet 0.15-0.02/0.01 MG (21/5) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35046000131", "ndc_label_name": "B Complex (Folic Acid) Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536478701", "ndc_label_name": "B Complex Capsule Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845006011", "ndc_label_name": "B Complex CAPSULE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629066170", "ndc_label_name": "B Complex CAPSULE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629066180", "ndc_label_name": "B Complex CAPSULE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629056301", "ndc_label_name": "B Complex Formula 1 (Lipotrop) Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629056102", "ndc_label_name": "B Complex Vitamins (w/ FA) Capsule Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00761044820", "ndc_label_name": "B Complex Vitamins CAPSULE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845060101", "ndc_label_name": "B Complex Vitamins CAPSULE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629056001", "ndc_label_name": "B Complex Vitamins CAPSULE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40093010175", "ndc_label_name": "B Complex-C-Folic Acid TABLET Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845005661", "ndc_label_name": "B-1 TABLET 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312000770", "ndc_label_name": "B-100 Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312000772", "ndc_label_name": "B-100 Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845005741", "ndc_label_name": "B-12 TABLET 100 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135065201", "ndc_label_name": "B-12 Tablet 1000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135065263", "ndc_label_name": "B-12 Tablet 1000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10135065250", "ndc_label_name": "B-12 Tablet 1000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40093010602", "ndc_label_name": "B-12 Tablet 1000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40986002222", "ndc_label_name": "B-12 TABLET 250 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845005731", "ndc_label_name": "B-12 TABLET 50 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917013971", "ndc_label_name": "B-12 TABLET 500 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007930", "ndc_label_name": "B-12 TABLET 500 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985022309", "ndc_label_name": "B-12 TABLET 500 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312058911", "ndc_label_name": "B-12 Tablet Sublingual 2500 MCG Sublingual", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985027112", "ndc_label_name": "B-12 Tablet Sublingual 2500 MCG Sublingual", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "81131011143", "ndc_label_name": "B-12 Tablet Sublingual 2500 MCG Sublingual", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917013963", "ndc_label_name": "B-12 TR Tablet Extended Release 1000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917013964", "ndc_label_name": "B-12 TR Tablet Extended Release 1000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007932", "ndc_label_name": "B-12 TR Tablet Extended Release 1000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "31604002730", "ndc_label_name": "B-12 TR Tablet Extended Release 1000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845007141", "ndc_label_name": "B-2 TABLET 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35046000120", "ndc_label_name": "B-2 Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35046000124", "ndc_label_name": "B-6 Tablet 250 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "30768000601", "ndc_label_name": "B-Complex (Folic Acid) Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007941", "ndc_label_name": "B-Complex Balanced TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917004416", "ndc_label_name": "B-Complex-C (w/Folic Acid) Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917006546", "ndc_label_name": "B-Complex-C (w/Folic Acid) Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312000530", "ndc_label_name": "B-Complex/Folic Acid/Vitamin C Tablet Extended Release Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917013858", "ndc_label_name": "B-Complex/Vitamin C TABLET Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917013935", "ndc_label_name": "B-Complex/Vitamin C TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10267102701", "ndc_label_name": "B-Plex Plus TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10267102705", "ndc_label_name": "B-Plex Plus TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10267102505", "ndc_label_name": "B-Plex TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10267102501", "ndc_label_name": "B-Plex TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00225055050", "ndc_label_name": "Baby Ayr Saline SOLUTION 0.65 % NASAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "46672005350", "ndc_label_name": "Bac Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "46672005310", "ndc_label_name": "Bac Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69784088035", "ndc_label_name": "Baciguent Ointment 500 UNIT/GM Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478071935", "ndc_label_name": "Bacitra-Neomycin-Polymyxin-HC Ointment 1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267095535", "ndc_label_name": "Bacitra-Neomycin-Polymyxin-HC OINTMENT 1 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208078555", "ndc_label_name": "Bacitra-Neomycin-Polymyxin-HC OINTMENT 1 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999065335", "ndc_label_name": "Bacitra-Neomycin-Polymyxin-HC OINTMENT 1 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959023803", "ndc_label_name": "Bacitra-Neomycin-Polymyxin-HC Ointment 1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672200501", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802006001", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917018788", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917005749", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959021706", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205027510", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41268093004", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00713028031", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "53217013101", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090084600", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959021703", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49614041810", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "59390002617", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802006070", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090084500", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33261098101", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "71205005701", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569553600", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "59390002601", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49999014215", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090081500", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802006003", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569553900", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569545300", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "61919011630", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "59390002662", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267098830", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66267098915", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67777021901", "ndc_label_name": "Bacitracin Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00574402235", "ndc_label_name": "Bacitracin OINTMENT 500 UNIT/GM OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168001131", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917016408", "ndc_label_name": "Bacitracin Zinc OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917011354", "ndc_label_name": "Bacitracin Zinc OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00168001104", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917016394", "ndc_label_name": "Bacitracin Zinc OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904667967", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00168001116", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917014221", "ndc_label_name": "Bacitracin Zinc OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00472110556", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54162001728", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16784011733", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00168011109", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33261070701", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090276600", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00168001135", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "14428000888", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "14428000944", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "53217002801", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090327900", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16784011731", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800008902", "ndc_label_name": "Bacitracin Zinc OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67777022007", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00472110534", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959011303", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51672207501", "ndc_label_name": "Bacitracin Zinc OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000047001", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959011330", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "72189006830", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54162001709", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959011315", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51824000301", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959011344", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51672207502", "ndc_label_name": "Bacitracin Zinc OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "69396002701", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "72189004430", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54162001715", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58980001110", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569240900", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68071132400", "ndc_label_name": "Bacitracin Zinc OINTMENT 500 UNIT/GM EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "69396000820", "ndc_label_name": "Bacitracin Zinc Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000054701", "ndc_label_name": "Bacitracin Zinc-Aloe Ointment 500 UNIT/GM External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090327400", "ndc_label_name": "Bacitracin-Polymyxin B Ointment 500-10000 UNIT/GM Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208055555", "ndc_label_name": "Bacitracin-Polymyxin B OINTMENT 500-10000 UNIT/GM OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267092535", "ndc_label_name": "Bacitracin-Polymyxin B OINTMENT 500-10000 UNIT/GM OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72189001735", "ndc_label_name": "Bacitracin-Polymyxin B Ointment 500-10000 UNIT/GM Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569357000", "ndc_label_name": "Bacitracin-Polymyxin B Ointment 500-10000 UNIT/GM Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457056220", "ndc_label_name": "Baclofen Solution 10 MG/20ML Intrathecal", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72834060216", "ndc_label_name": "Baclofen Solution 10 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52817062008", "ndc_label_name": "Baclofen Solution 10 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68134040316", "ndc_label_name": "Baclofen Solution 10 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457056320", "ndc_label_name": "Baclofen Solution 20000 MCG/20ML Intrathecal", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457056420", "ndc_label_name": "Baclofen Solution 40 MG/20ML Intrathecal", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52817061916", "ndc_label_name": "Baclofen Solution 5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72888010324", "ndc_label_name": "Baclofen Solution 5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68134040116", "ndc_label_name": "Baclofen Solution 5 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559020412", "ndc_label_name": "Baclofen Suspension 25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52536060012", "ndc_label_name": "Baclofen Suspension 25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559020403", "ndc_label_name": "Baclofen Suspension 25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52536060011", "ndc_label_name": "Baclofen Suspension 25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72162234204", "ndc_label_name": "Baclofen Suspension 25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72162234202", "ndc_label_name": "Baclofen Suspension 25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71225014001", "ndc_label_name": "Baclofen Suspension 25 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603240621", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00172409660", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603240628", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00172409680", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378302301", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001014", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001020", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603240630", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832102400", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527133001", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832105415", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378302310", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603240602", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001015", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291015890", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832102410", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135053210", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832102450", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135053201", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440718030", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603240632", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358004230", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063086430", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904647561", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001002", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544017290", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001060", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527133010", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714007104", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999060790", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999060700", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714007106", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001028", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001021", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999060701", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832105410", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001007", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436902201", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289075760", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001030", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001090", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001099", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090165003", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832105411", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291015810", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52817032000", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919009386", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063086490", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358004201", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999060730", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090249301", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358004260", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063086460", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959073300", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739000710", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999060745", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700040330", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090165001", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959073302", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090165000", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999060760", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919009330", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739047910", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52817032010", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760040960", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090249303", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569433000", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436902205", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436902202", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187014790", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874062020", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959073390", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919002630", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436902203", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569433003", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959073310", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55154763500", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629128601", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788979609", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289075730", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919009372", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959073312", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700040301", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569433001", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700040390", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874062040", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788984606", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700014130", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629128602", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959073318", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118102403", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760040990", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919002690", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788052206", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70710128505", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700040360", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629128603", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959073320", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118102409", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187014730", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187014778", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71930000612", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335020603", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919002660", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874062004", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959073330", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187014760", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187031372", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187031360", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959073340", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335020606", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919009360", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187031390", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959073360", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187031330", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187031378", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629128605", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868340501", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335020609", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919009390", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874062060", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289075790", "ndc_label_name": "Baclofen TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629128604", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629128608", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084085501", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118102406", "ndc_label_name": "Baclofen TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335034406", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267061790", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70710128500", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629128609", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629128606", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874062001", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335020602", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874062090", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335034407", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544067192", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335020605", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267061760", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629128607", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267061730", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335020608", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788984603", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335034409", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084085511", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335034404", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788984609", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874062010", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788979603", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874062030", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335020601", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544067160", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335020607", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544067180", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335020604", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788052203", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788979606", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788052209", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335034401", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70710128501", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335034402", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335020600", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335034408", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335034400", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335034403", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335034405", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71930000613", "ndc_label_name": "Baclofen Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52817031810", "ndc_label_name": "Baclofen Tablet 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70710166601", "ndc_label_name": "Baclofen Tablet 15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832105510", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440718130", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378302405", "ndc_label_name": "Baclofen TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832105511", "ndc_label_name": "Baclofen TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527133701", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291015950", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00172409760", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378302401", "ndc_label_name": "Baclofen TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063008560", "ndc_label_name": "Baclofen TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527133705", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603240728", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959067760", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358004360", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52817032110", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00172409780", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832102500", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063086530", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603240721", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904647661", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760017790", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436902302", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760041090", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832105515", "ndc_label_name": "Baclofen TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832102510", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090180101", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603240732", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135053305", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919009586", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959067710", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629319306", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358004390", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135053301", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959067745", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832102550", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714007204", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629319302", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569417101", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739097410", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356073690", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700040801", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868300600", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714007205", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356073660", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629319305", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569417102", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267087260", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063086560", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700040830", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700040860", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358004330", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090180102", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874102504", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700023630", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638409", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436902301", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919009560", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700040890", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356073630", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959067790", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874102506", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919009590", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610039145", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959067702", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629319307", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919009530", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063008530", "ndc_label_name": "Baclofen TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118102509", "ndc_label_name": "Baclofen TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267087291", "ndc_label_name": "Baclofen TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629319303", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063086590", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959067730", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084086811", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629319300", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436902303", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760017760", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638403", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874102509", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52817032100", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629319301", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638406", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874102501", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919002730", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760041060", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788690308", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335094900", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739048010", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629319304", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788690301", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267087290", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874102502", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629319308", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70710128605", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610039192", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874102503", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267087230", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788690306", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788690303", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788690309", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874102500", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335010300", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71930000712", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788973503", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084086801", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610039160", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638408", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788973509", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788638401", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70710128600", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70710128601", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335010303", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335010306", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71930000713", "ndc_label_name": "Baclofen Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52817031910", "ndc_label_name": "Baclofen Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72834052330", "ndc_label_name": "Baclofen Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00682300101", "ndc_label_name": "Bacmin TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69387000101", "ndc_label_name": "Bafiertam Capsule Delayed Release 95 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54629066203", "ndc_label_name": "Balance B-100 TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629013105", "ndc_label_name": "Balance B-100 TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292022311", "ndc_label_name": "Balanced B-50 Complex TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "75854060202", "ndc_label_name": "Balcoltra Tablet 0.1-20 MG-MCG(21) Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75854060203", "ndc_label_name": "Balcoltra Tablet 0.1-20 MG-MCG(21) Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75854060228", "ndc_label_name": "Balcoltra Tablet 0.1-20 MG-MCG(21) Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291015728", "ndc_label_name": "Balsalazide Disodium Capsule 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054007928", "ndc_label_name": "Balsalazide Disodium CAPSULE 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268010211", "ndc_label_name": "Balsalazide Disodium CAPSULE 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429095228", "ndc_label_name": "Balsalazide Disodium Capsule 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68682075002", "ndc_label_name": "Balsalazide Disodium Capsule 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268010213", "ndc_label_name": "Balsalazide Disodium CAPSULE 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505257507", "ndc_label_name": "Balsalazide Disodium CAPSULE 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084079933", "ndc_label_name": "Balsalazide Disodium CAPSULE 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084079932", "ndc_label_name": "Balsalazide Disodium CAPSULE 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59676003056", "ndc_label_name": "Balversa Tablet 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59676003084", "ndc_label_name": "Balversa Tablet 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59676004056", "ndc_label_name": "Balversa Tablet 4 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59676004028", "ndc_label_name": "Balversa Tablet 4 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59676005028", "ndc_label_name": "Balversa Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555903479", "ndc_label_name": "Balziva TABLET 0.4-35 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555903458", "ndc_label_name": "Balziva TABLET 0.4-35 MG-MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904530660", "ndc_label_name": "Banophen Capsule 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904203524", "ndc_label_name": "Banophen Capsule 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904530624", "ndc_label_name": "Banophen Capsule 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904530680", "ndc_label_name": "Banophen Capsule 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904530760", "ndc_label_name": "Banophen CAPSULE 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904530780", "ndc_label_name": "Banophen CAPSULE 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904122800", "ndc_label_name": "Banophen Liquid 12.5 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904517416", "ndc_label_name": "Banophen Liquid 12.5 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904555159", "ndc_label_name": "Banophen TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904555124", "ndc_label_name": "Banophen TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "62856058446", "ndc_label_name": "Banzel Suspension 40 MG/ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62856058252", "ndc_label_name": "Banzel Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62856058352", "ndc_label_name": "Banzel Tablet 400 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00002614511", "ndc_label_name": "Baqsimi One Pack Powder 3 MG/DOSE Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00548835101", "ndc_label_name": "Baqsimi One Pack Powder 3 MG/DOSE Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00548835202", "ndc_label_name": "Baqsimi Two Pack Powder 3 MG/DOSE Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00002614527", "ndc_label_name": "Baqsimi Two Pack Powder 3 MG/DOSE Nasal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00003161412", "ndc_label_name": "Baraclude SOLUTION 0.05 MG/ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00003161113", "ndc_label_name": "Baraclude TABLET 0.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00003161112", "ndc_label_name": "Baraclude TABLET 0.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00003161212", "ndc_label_name": "Baraclude TABLET 1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08011802055", "ndc_label_name": "Bardia Bulb Irrigation Syringe 60 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08011802065", "ndc_label_name": "Bardia Piston Irrigation Syr 60 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00002771501", "ndc_label_name": "Basaglar KwikPen Solution Pen-injector 100 UNIT/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00002771559", "ndc_label_name": "Basaglar KwikPen Solution Pen-injector 100 UNIT/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00002821405", "ndc_label_name": "Basaglar Tempo Pen Solution Pen-Injector 100 UNIT/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00002821401", "ndc_label_name": "Basaglar Tempo Pen Solution Pen-Injector 100 UNIT/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44087353501", "ndc_label_name": "Bavencio Solution 200 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70842010101", "ndc_label_name": "Baxdela TABLET 450 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70842010102", "ndc_label_name": "Baxdela Tablet 450 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70842010103", "ndc_label_name": "Baxdela Tablet 450 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "08290305500", "ndc_label_name": "BD Allergy Syringe 28G X 1/2\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290550002", "ndc_label_name": "BD Allergy Syringe 28G X 1/2\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290550003", "ndc_label_name": "BD Allergy Syringe 28G X 1/2\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290525506", "ndc_label_name": "BD Assure BPM/Auto Arm Cuff", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290525508", "ndc_label_name": "BD Assure BPM/Auto Wrist Cuff", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290525507", "ndc_label_name": "BD Assure BPM/Deluxe Arm Cuff", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290525505", "ndc_label_name": "BD Assure BPM/Manual Arm Cuff", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290525509", "ndc_label_name": "BD Assure BPM/Port Wristwatch", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290329515", "ndc_label_name": "BD AutoShield Duo 30G X 5 MM", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309695", "ndc_label_name": "BD Control Syring Luer-Lok 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290306413", "ndc_label_name": "BD Heparin PosiFlush Solution 10 UNIT/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "08290306423", "ndc_label_name": "BD Heparin PosiFlush Solution 100 UNIT/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "08290326730", "ndc_label_name": "BD Insulin Syringe U-500 31G X 6MM 0.5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08290328440", "ndc_label_name": "BD Insulin Syringe U/F 1/2Unit 31G X 5/16\" 0.3 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290328431", "ndc_label_name": "BD Insulin Syringe U/F 30G X 1/2\" 0.3 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290328466", "ndc_label_name": "BD Insulin Syringe U/F 30G X 1/2\" 0.5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290328411", "ndc_label_name": "BD Insulin Syringe U/F 30G X 1/2\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290328438", "ndc_label_name": "BD Insulin Syringe U/F 31G X 5/16\" 0.3 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290328468", "ndc_label_name": "BD Insulin Syringe U/F 31G X 5/16\" 0.5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290328418", "ndc_label_name": "BD Insulin Syringe U/F 31G X 5/16\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290302995", "ndc_label_name": "BD Luer-Lok Syringe 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309644", "ndc_label_name": "BD Luer-Lok Syringe 20G X 1\" 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309634", "ndc_label_name": "BD Luer-Lok Syringe 20G X 1\" 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309645", "ndc_label_name": "BD Luer-Lok Syringe 20G X 1-1/2\" 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309635", "ndc_label_name": "BD Luer-Lok Syringe 20G X 1-1/2\" 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309638", "ndc_label_name": "BD Luer-Lok Syringe 21G X 1\" 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309642", "ndc_label_name": "BD Luer-Lok Syringe 21G X 1\" 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309632", "ndc_label_name": "BD Luer-Lok Syringe 21G X 1\" 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309698", "ndc_label_name": "BD Luer-Lok Syringe 21G X 1\" 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309639", "ndc_label_name": "BD Luer-Lok Syringe 21G X 1-1/2\" 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309643", "ndc_label_name": "BD Luer-Lok Syringe 21G X 1-1/2\" 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309699", "ndc_label_name": "BD Luer-Lok Syringe 21G X 1-1/2\" 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309633", "ndc_label_name": "BD Luer-Lok Syringe 21G X 1-1/2\" 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309640", "ndc_label_name": "BD Luer-Lok Syringe 22G X 1\" 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309572", "ndc_label_name": "BD Luer-Lok Syringe 22G X 1\" 3 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309630", "ndc_label_name": "BD Luer-Lok Syringe 22G X 1\" 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309574", "ndc_label_name": "BD Luer-Lok Syringe 22G X 1-1/2\" 3 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309631", "ndc_label_name": "BD Luer-Lok Syringe 22G X 1-1/2\" 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309581", "ndc_label_name": "BD Luer-Lok Syringe 25G X 1\" 3 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290366592", "ndc_label_name": "BD Microtainer Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290366594", "ndc_label_name": "BD Microtainer Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290366593", "ndc_label_name": "BD Microtainer Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08290320749", "ndc_label_name": "BD Pen Needle Micro U/F 32G X 6 MM", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290320119", "ndc_label_name": "BD Pen Needle Mini U/F 31G X 5 MM", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290320550", "ndc_label_name": "BD Pen Needle Nano 2nd Gen 32G X 4 MM", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290320122", "ndc_label_name": "BD Pen Needle Nano U/F 32G X 4 MM", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290328203", "ndc_label_name": "BD Pen Needle Original U/F 29G X 12.7MM", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290320109", "ndc_label_name": "BD Pen Needle Short U/F 31G X 8 MM", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309657", "ndc_label_name": "BD Plastipak Syringe 3 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290305918", "ndc_label_name": "BD SafetyGlide Needle 18G X 1-1/2\"", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290305907", "ndc_label_name": "BD SafetyGlide Shielded Needle 22G X 1-1/2\" 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290305927", "ndc_label_name": "BD SafetyGlide Syringe/Needle 27G X 5/8\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290326895", "ndc_label_name": "BD Swab Single Use Regular Pad", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290006893", "ndc_label_name": "BD Swabs Single Use Butterfly Pad", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309653", "ndc_label_name": "BD Syringe 50 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290303348", "ndc_label_name": "BD Syringe Blunt Cannula 17G 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290303393", "ndc_label_name": "BD Syringe Dual Cannula 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290301625", "ndc_label_name": "BD Syringe Luer Slip Tip 20 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290301603", "ndc_label_name": "BD Syringe Luer Slip Tip 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309647", "ndc_label_name": "BD Syringe Luer Slip Tip 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309628", "ndc_label_name": "BD Syringe Luer-Lok 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290302830", "ndc_label_name": "BD Syringe Luer-Lok 20 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290301031", "ndc_label_name": "BD Syringe Luer-Lok 20 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309661", "ndc_label_name": "BD Syringe Luer-Lok 20 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290302832", "ndc_label_name": "BD Syringe Luer-Lok 30 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290305618", "ndc_label_name": "BD Syringe Luer-Lok 30 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290301033", "ndc_label_name": "BD Syringe Luer-Lok 30 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290301027", "ndc_label_name": "BD Syringe Luer-Lok 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309646", "ndc_label_name": "BD Syringe Luer-Lok 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309703", "ndc_label_name": "BD Syringe Luer-Lok 5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08290309659", "ndc_label_name": "BD Syringe Slip Tip 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290301025", "ndc_label_name": "BD Syringe Slip Tip 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309701", "ndc_label_name": "BD Syringe Slip Tip 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290303134", "ndc_label_name": "BD Syringe Slip Tip 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290301030", "ndc_label_name": "BD Syringe Slip Tip 10 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309626", "ndc_label_name": "BD Syringe Slip Tip 25G X 5/8\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309625", "ndc_label_name": "BD Syringe Slip Tip 26G X 3/8\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290309624", "ndc_label_name": "BD TB Syringe 21G X 1\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290305946", "ndc_label_name": "BD TB Syringe 26G X 3/8\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290005620", "ndc_label_name": "BD TB Syringe 27G X 1/2\" 0.5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290305620", "ndc_label_name": "BD TB Syringe 27G X 1/2\" 0.5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290324910", "ndc_label_name": "BD Veo Insulin Syr U/F 1/2Unit 31G X 15/64\" 0.3 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290324909", "ndc_label_name": "BD Veo Insulin Syringe U/F 31G X 15/64\" 0.3 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290324911", "ndc_label_name": "BD Veo Insulin Syringe U/F 31G X 15/64\" 0.5 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290324912", "ndc_label_name": "BD Veo Insulin Syringe U/F 31G X 15/64\" 1 ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290256094", "ndc_label_name": "BD Veritor Home Covid-19 Test Kit In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08290256094", "ndc_label_name": "BDVeritor At-Home Covid19 Test Kit In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292055523", "ndc_label_name": "BEC/Zinc TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00173038879", "ndc_label_name": "Beconase AQ Suspension 42 MCG/SPRAY Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569172901", "ndc_label_name": "Beconase AQ Suspension 42 MCG/SPRAY Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59385002260", "ndc_label_name": "Belbuca Film 150 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002201", "ndc_label_name": "Belbuca Film 150 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63481020760", "ndc_label_name": "Belbuca FILM 150 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63481034860", "ndc_label_name": "Belbuca FILM 300 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002301", "ndc_label_name": "Belbuca Film 300 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002360", "ndc_label_name": "Belbuca Film 300 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63481051960", "ndc_label_name": "Belbuca FILM 450 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002460", "ndc_label_name": "Belbuca Film 450 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002401", "ndc_label_name": "Belbuca Film 450 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002501", "ndc_label_name": "Belbuca Film 600 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002560", "ndc_label_name": "Belbuca Film 600 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63481068560", "ndc_label_name": "Belbuca FILM 600 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002101", "ndc_label_name": "Belbuca Film 75 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63481016160", "ndc_label_name": "Belbuca FILM 75 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002160", "ndc_label_name": "Belbuca Film 75 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63481082060", "ndc_label_name": "Belbuca FILM 750 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002601", "ndc_label_name": "Belbuca Film 750 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002660", "ndc_label_name": "Belbuca Film 750 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002701", "ndc_label_name": "Belbuca Film 900 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59385002760", "ndc_label_name": "Belbuca Film 900 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63481095260", "ndc_label_name": "Belbuca FILM 900 MCG Buccal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68152010809", "ndc_label_name": "Beleodaq Solution Reconstituted 500 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42367052125", "ndc_label_name": "Belrapzo Solution 100 MG/4ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00006003310", "ndc_label_name": "Belsomra TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00006003330", "ndc_label_name": "Belsomra TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00006032510", "ndc_label_name": "Belsomra TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00006032530", "ndc_label_name": "Belsomra TABLET 15 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00006033530", "ndc_label_name": "Belsomra TABLET 20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00006033510", "ndc_label_name": "Belsomra TABLET 20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00006000510", "ndc_label_name": "Belsomra TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00006000530", "ndc_label_name": "Belsomra TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016190", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093512501", "ndc_label_name": "Benazepril HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261017990", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185005305", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016101", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719090", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093512505", "ndc_label_name": "Benazepril HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358004830", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079014501", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781189201", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063028890", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378044301", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959084130", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811062810", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185005301", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063028830", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079014520", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016150", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090091202", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719030", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217019030", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547033650", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544056630", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090091200", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760035190", "ndc_label_name": "Benazepril HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547033610", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011015", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261017930", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569566802", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011011", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544056690", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569566800", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919028060", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919028030", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304033805", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261017960", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788905109", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959084160", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811062850", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700029030", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629267201", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162075250", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569566801", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760008190", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629267203", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118033809", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700029090", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304033801", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118033808", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862011601", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629267202", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162075210", "ndc_label_name": "Benazepril HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429015990", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788994709", "ndc_label_name": "Benazepril HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544055430", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544055490", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093512601", "ndc_label_name": "Benazepril HCl TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429016090", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547033710", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185082005", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093512605", "ndc_label_name": "Benazepril HCl TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811062950", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063040330", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261018030", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185082001", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187039390", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458086316", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378044401", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063013130", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261018002", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090091301", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016201", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719230", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629172803", "ndc_label_name": "Benazepril HCl TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187039330", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719290", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090324301", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016250", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090324300", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999075930", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261018060", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874112301", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079014620", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090091300", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011111", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547033750", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458086310", "ndc_label_name": "Benazepril HCl TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569566901", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261018090", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162075310", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919073990", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700029130", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011115", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079014601", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304033905", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700029190", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358004930", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429016001", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629172801", "ndc_label_name": "Benazepril HCl TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304033901", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569566900", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071014660", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016218", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429016018", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118033908", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162075350", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016290", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760008290", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118033909", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071014690", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547033703", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760035290", "ndc_label_name": "Benazepril HCl TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429016005", "ndc_label_name": "Benazepril HCl TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071014630", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959083130", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862011701", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629172802", "ndc_label_name": "Benazepril HCl TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874112303", "ndc_label_name": "Benazepril HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071014691", "ndc_label_name": "Benazepril HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016350", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093512701", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719390", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063013230", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811063050", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261084690", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261084630", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719330", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011215", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378044701", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811063010", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959083530", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261084660", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016318", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063074830", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016390", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031790", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261084600", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090335900", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569567001", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016301", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063078730", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011211", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090091400", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788724803", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569567000", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959083560", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118034009", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547033803", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162075450", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700031730", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090091401", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547033810", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187090690", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458086210", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760008330", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547033850", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071002660", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304034005", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629292301", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090335901", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304034001", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458086216", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862011801", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118034003", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205032030", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788724801", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071002630", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919075690", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071002690", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187090630", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084073995", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629292302", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084073925", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896808", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788695701", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788695708", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788695709", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162075410", "ndc_label_name": "Benazepril HCl TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788724806", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788724808", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896803", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788695703", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896806", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896801", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896809", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788695706", "ndc_label_name": "Benazepril HCl TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788724809", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788905303", "ndc_label_name": "Benazepril HCl Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185050501", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185050505", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781189101", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016050", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811062710", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093512401", "ndc_label_name": "Benazepril HCl TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356058790", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162075150", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378044101", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268010915", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356058760", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016090", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356058730", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291016001", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289096330", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547033510", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217007690", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217007660", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629267901", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268010911", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162075110", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217007630", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118033703", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429015890", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788636106", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118033709", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304033701", "ndc_label_name": "Benazepril HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788636101", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788905003", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788636103", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788636108", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788636109", "ndc_label_name": "Benazepril HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832048311", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629180901", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261045360", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00574022701", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429040401", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185032501", "ndc_label_name": "Benazepril-Hydrochlorothiazide TABLET 10-12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261045390", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378473501", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505026201", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261045330", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358004730", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629180902", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980019401", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 10-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832048411", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118474509", "ndc_label_name": "Benazepril-Hydrochlorothiazide TABLET 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185021101", "ndc_label_name": "Benazepril-Hydrochlorothiazide TABLET 20-12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118474503", "ndc_label_name": "Benazepril-Hydrochlorothiazide TABLET 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378474501", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505026301", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429040501", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629268003", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00574022901", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980019501", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629268001", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629268002", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 20-12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980019601", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429040601", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118477503", "ndc_label_name": "Benazepril-Hydrochlorothiazide TABLET 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00574022801", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569568500", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832048511", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358005030", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185027701", "ndc_label_name": "Benazepril-Hydrochlorothiazide TABLET 20-25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505026401", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118477509", "ndc_label_name": "Benazepril-Hydrochlorothiazide TABLET 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569568501", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378477501", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959090730", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629273501", "ndc_label_name": "Benazepril-Hydrochlorothiazide Tablet 20-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429040301", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118472503", "ndc_label_name": "Benazepril-Hydrochlorothiazide TABLET 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378472501", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118472509", "ndc_label_name": "Benazepril-Hydrochlorothiazide TABLET 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185023601", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505026101", "ndc_label_name": "Benazepril-hydroCHLOROthiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42367052025", "ndc_label_name": "Bendamustine HCl Solution 100 MG/4ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001057241", "ndc_label_name": "Bendamustine HCl Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150039201", "ndc_label_name": "Bendamustine HCl Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288010320", "ndc_label_name": "Bendamustine HCl Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729025105", "ndc_label_name": "Bendamustine HCl Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505609600", "ndc_label_name": "Bendamustine HCl Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150039101", "ndc_label_name": "Bendamustine HCl Solution Reconstituted 25 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001057141", "ndc_label_name": "Bendamustine HCl Solution Reconstituted 25 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505609500", "ndc_label_name": "Bendamustine HCl Solution Reconstituted 25 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288010210", "ndc_label_name": "Bendamustine HCl Solution Reconstituted 25 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729025003", "ndc_label_name": "Bendamustine HCl Solution Reconstituted 25 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63459034804", "ndc_label_name": "Bendeka SOLUTION 100 MG/4ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58394063503", "ndc_label_name": "BeneFIX KIT 1000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58394063603", "ndc_label_name": "BeneFIX KIT 2000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58394063303", "ndc_label_name": "BeneFIX KIT 250 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58394063703", "ndc_label_name": "BeneFIX KIT 3000 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58394063403", "ndc_label_name": "BeneFIX KIT 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65597010590", "ndc_label_name": "Benicar HCT Tablet 20-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010530", "ndc_label_name": "Benicar HCT Tablet 20-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356028840", "ndc_label_name": "Benicar HCT TABLET 40-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569599800", "ndc_label_name": "Benicar HCT Tablet 40-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090108300", "ndc_label_name": "Benicar HCT Tablet 40-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010630", "ndc_label_name": "Benicar HCT Tablet 40-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010690", "ndc_label_name": "Benicar HCT Tablet 40-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569590300", "ndc_label_name": "Benicar HCT Tablet 40-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010790", "ndc_label_name": "Benicar HCT Tablet 40-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289044330", "ndc_label_name": "Benicar HCT Tablet 40-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356025890", "ndc_label_name": "Benicar HCT TABLET 40-25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010730", "ndc_label_name": "Benicar HCT Tablet 40-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356028940", "ndc_label_name": "Benicar HCT TABLET 40-25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010390", "ndc_label_name": "Benicar Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090087700", "ndc_label_name": "Benicar Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629339004", "ndc_label_name": "Benicar Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629339002", "ndc_label_name": "Benicar Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569560600", "ndc_label_name": "Benicar Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629339003", "ndc_label_name": "Benicar Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999081530", "ndc_label_name": "Benicar TABLET 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010303", "ndc_label_name": "Benicar TABLET 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629339001", "ndc_label_name": "Benicar Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010330", "ndc_label_name": "Benicar Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010403", "ndc_label_name": "Benicar TABLET 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010490", "ndc_label_name": "Benicar Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289043630", "ndc_label_name": "Benicar Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010430", "ndc_label_name": "Benicar Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65597010130", "ndc_label_name": "Benicar Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356028720", "ndc_label_name": "Benicar TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356028730", "ndc_label_name": "Benicar TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49401008835", "ndc_label_name": "Benlysta Solution Auto-injector 200 MG/ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49401008801", "ndc_label_name": "Benlysta Solution Auto-injector 200 MG/ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49401008802", "ndc_label_name": "Benlysta Solution Auto-injector 200 MG/ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49401008847", "ndc_label_name": "Benlysta Solution Prefilled Syringe 200 MG/ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49401008842", "ndc_label_name": "Benlysta Solution Prefilled Syringe 200 MG/ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49401010101", "ndc_label_name": "Benlysta SOLUTION RECONSTITUTED 120 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49401010201", "ndc_label_name": "Benlysta SOLUTION RECONSTITUTED 400 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63801010701", "ndc_label_name": "Bensal HP Ointment 3 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569525900", "ndc_label_name": "BenzaClin Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187519025", "ndc_label_name": "BenzaClin Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187519035", "ndc_label_name": "BenzaClin with Pump Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356022050", "ndc_label_name": "BenzaClin with Pump Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187519050", "ndc_label_name": "BenzaClin with Pump Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187520546", "ndc_label_name": "Benzamycin GEL 5-3 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00066051046", "ndc_label_name": "Benzamycin GEL 5-3 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187019410", "ndc_label_name": "BenzEFoam Foam 5.3 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10702034301", "ndc_label_name": "Benzhydrocodone-Acetaminophen Tablet 4.08-325 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10702034401", "ndc_label_name": "Benzhydrocodone-Acetaminophen Tablet 6.12-325 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10702034501", "ndc_label_name": "Benzhydrocodone-Acetaminophen Tablet 8.16-325 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64380071207", "ndc_label_name": "Benzonatate CAPSULE 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904590460", "ndc_label_name": "Benzonatate CAPSULE 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806071401", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904656460", "ndc_label_name": "Benzonatate CAPSULE 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904656461", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904665760", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380071206", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332042671", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877057301", "ndc_label_name": "Benzonatate CAPSULE 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224001050", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664013388", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224001060", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806071405", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877057305", "ndc_label_name": "Benzonatate CAPSULE 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162053650", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687034601", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69387011901", "ndc_label_name": "Benzonatate CAPSULE 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332042631", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162053610", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739002910", "ndc_label_name": "Benzonatate Capsule 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69387011905", "ndc_label_name": "Benzonatate CAPSULE 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382024705", "ndc_label_name": "Benzonatate CAPSULE 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452014320", "ndc_label_name": "Benzonatate CAPSULE 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877010501", "ndc_label_name": "Benzonatate CAPSULE 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452014330", "ndc_label_name": "Benzonatate CAPSULE 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382024701", "ndc_label_name": "Benzonatate CAPSULE 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806071501", "ndc_label_name": "Benzonatate Capsule 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452014420", "ndc_label_name": "Benzonatate CAPSULE 200 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806071505", "ndc_label_name": "Benzonatate Capsule 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224000150", "ndc_label_name": "Benzonatate CAPSULE 200 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877010605", "ndc_label_name": "Benzonatate CAPSULE 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877057505", "ndc_label_name": "Benzonatate CAPSULE 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722095801", "ndc_label_name": "Benzonatate Capsule 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332042771", "ndc_label_name": "Benzonatate Capsule 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332042731", "ndc_label_name": "Benzonatate Capsule 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224000160", "ndc_label_name": "Benzonatate CAPSULE 200 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69387012001", "ndc_label_name": "Benzonatate CAPSULE 200 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739012410", "ndc_label_name": "Benzonatate Capsule 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69387012005", "ndc_label_name": "Benzonatate CAPSULE 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664013488", "ndc_label_name": "Benzonatate Capsule 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380071307", "ndc_label_name": "Benzonatate CAPSULE 200 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162053710", "ndc_label_name": "Benzonatate Capsule 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452014430", "ndc_label_name": "Benzonatate CAPSULE 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380071306", "ndc_label_name": "Benzonatate Capsule 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162053750", "ndc_label_name": "Benzonatate Capsule 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877010601", "ndc_label_name": "Benzonatate CAPSULE 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877057501", "ndc_label_name": "Benzonatate CAPSULE 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71850181501", "ndc_label_name": "Benzoyl Peroxide Foam 9.8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51224040110", "ndc_label_name": "Benzoyl Peroxide Foam 9.8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49022045382", "ndc_label_name": "Benzoyl Peroxide GEL 10 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802030896", "ndc_label_name": "Benzoyl Peroxide GEL 10 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68752021060", "ndc_label_name": "Benzoyl Peroxide GEL 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802030801", "ndc_label_name": "Benzoyl Peroxide GEL 10 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569340500", "ndc_label_name": "Benzoyl Peroxide Gel 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959095902", "ndc_label_name": "Benzoyl Peroxide Gel 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54162001902", "ndc_label_name": "Benzoyl Peroxide Gel 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49999075045", "ndc_label_name": "Benzoyl Peroxide GEL 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802021601", "ndc_label_name": "Benzoyl Peroxide GEL 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33261042301", "ndc_label_name": "Benzoyl Peroxide Gel 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68752020560", "ndc_label_name": "Benzoyl Peroxide GEL 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802021696", "ndc_label_name": "Benzoyl Peroxide GEL 5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "72162233702", "ndc_label_name": "Benzoyl Peroxide Liquid 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802031801", "ndc_label_name": "Benzoyl Peroxide Liquid 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802031834", "ndc_label_name": "Benzoyl Peroxide Liquid 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536126163", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536135142", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49999050808", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35573045408", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67405083005", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35573045491", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67405083008", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 10 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536125919", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802028034", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "72162233802", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67405082505", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35573045308", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67405082508", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35573045391", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536125963", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802028001", "ndc_label_name": "Benzoyl Peroxide Wash Liquid 5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00781709459", "ndc_label_name": "Benzoyl Peroxide-Erythromycin Gel 5-3 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682090146", "ndc_label_name": "Benzoyl Peroxide-Erythromycin GEL 5-3 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682090023", "ndc_label_name": "Benzoyl Peroxide-Erythromycin Gel 5-3 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781705449", "ndc_label_name": "Benzoyl Peroxide-Erythromycin Gel 5-3 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980032801", "ndc_label_name": "Benzoyl Peroxide-Erythromycin GEL 5-3 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980032802", "ndc_label_name": "Benzoyl Peroxide-Erythromycin GEL 5-3 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10702004003", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063054114", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10702004050", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806008130", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090583701", "ndc_label_name": "Benzphetamine HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10702004001", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063054160", "ndc_label_name": "Benzphetamine HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806008101", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090102402", "ndc_label_name": "Benzphetamine HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063054145", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629413901", "ndc_label_name": "Benzphetamine HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063054130", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090583702", "ndc_label_name": "Benzphetamine HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063054198", "ndc_label_name": "Benzphetamine HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980014505", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980014501", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090102401", "ndc_label_name": "Benzphetamine HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063054190", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "75834010201", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "75834010205", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "75834010230", "ndc_label_name": "Benzphetamine HCl TABLET 50 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143923301", "ndc_label_name": "Benztropine Mesylate Solution 1 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143972905", "ndc_label_name": "Benztropine Mesylate SOLUTION 1 MG/ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143923305", "ndc_label_name": "Benztropine Mesylate Solution 1 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382086002", "ndc_label_name": "Benztropine Mesylate Solution 1 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143972901", "ndc_label_name": "Benztropine Mesylate Solution 1 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382086010", "ndc_label_name": "Benztropine Mesylate Solution 1 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323097002", "ndc_label_name": "Benztropine Mesylate SOLUTION 1 MG/ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00603243721", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243332", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135060610", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243321", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097082607", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69315013601", "ndc_label_name": "Benztropine Mesylate TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11534016703", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904678861", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243732", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353070709", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64720014310", "ndc_label_name": "Benztropine Mesylate TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011511", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832108000", "ndc_label_name": "Benztropine Mesylate TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64720014311", "ndc_label_name": "Benztropine Mesylate TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687035601", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353091309", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135060601", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385010301", "ndc_label_name": "Benztropine Mesylate TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687035611", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559057001", "ndc_label_name": "Benztropine Mesylate TABLET 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11534016701", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011515", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084038111", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385010310", "ndc_label_name": "Benztropine Mesylate TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64125013601", "ndc_label_name": "Benztropine Mesylate TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69315013610", "ndc_label_name": "Benztropine Mesylate TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64125013610", "ndc_label_name": "Benztropine Mesylate TABLET 0.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084038101", "ndc_label_name": "Benztropine Mesylate Tablet 0.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904654061", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719530", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243821", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719592", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079022117", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719560", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832108100", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353079653", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629412101", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719590", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353058053", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243421", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060010", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243432", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11534016801", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011611", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060015", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243832", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187084003", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832108110", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097082707", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135060701", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353058030", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687036801", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69315013710", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11534016803", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64125013701", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904679061", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385010401", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261018130", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060060", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687036811", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64720014411", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060020", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084038801", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135060710", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261018160", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060030", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69315013701", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011615", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063026790", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084038811", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353079630", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864005506", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079022119", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097082715", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569901000", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559057101", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060014", "ndc_label_name": "Benztropine Mesylate Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385010410", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64125013710", "ndc_label_name": "Benztropine Mesylate TABLET 1 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243532", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874056510", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719630", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832108200", "ndc_label_name": "Benztropine Mesylate TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719692", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719690", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243921", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440719660", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874056512", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874056530", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11534016903", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00832108210", "ndc_label_name": "Benztropine Mesylate TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243521", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904678961", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135060801", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603243932", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097083215", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385010501", "ndc_label_name": "Benztropine Mesylate TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864005630", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011711", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090269500", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135060810", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11534016901", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268011715", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69315013810", "ndc_label_name": "Benztropine Mesylate TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569905700", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687037901", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874056501", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919012830", "ndc_label_name": "Benztropine Mesylate TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097083207", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687037911", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64125013801", "ndc_label_name": "Benztropine Mesylate TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874056515", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084038901", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559057201", "ndc_label_name": "Benztropine Mesylate TABLET 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874056520", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64125013810", "ndc_label_name": "Benztropine Mesylate TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874056560", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69315013801", "ndc_label_name": "Benztropine Mesylate TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084038911", "ndc_label_name": "Benztropine Mesylate Tablet 2 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385010510", "ndc_label_name": "Benztropine Mesylate TABLET 2 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078082761", "ndc_label_name": "Beovu Solution 6 MG/0.05ML Intravitreal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00078082760", "ndc_label_name": "Beovu Solution Prefilled Syringe 6 MG/0.05ML Intravitreal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505611101", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378705567", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208063010", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505611102", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82260063005", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378705535", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332059810", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069071101", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069071201", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208063005", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82260063010", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332059805", "ndc_label_name": "Bepotastine Besilate Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208062902", "ndc_label_name": "Bepreve Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208062901", "ndc_label_name": "Bepreve Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569625400", "ndc_label_name": "Bepreve Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569629300", "ndc_label_name": "Bepreve Solution 1.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069200414", "ndc_label_name": "Beqvez Suspension Therapy Pack 4 x 1 ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069200404", "ndc_label_name": "Beqvez Suspension Therapy Pack 4 x 1 ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069200505", "ndc_label_name": "Beqvez Suspension Therapy Pack 5 x 1 ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069200515", "ndc_label_name": "Beqvez Suspension Therapy Pack 5 x 1 ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069200606", "ndc_label_name": "Beqvez Suspension Therapy Pack 6 x 1 ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069200616", "ndc_label_name": "Beqvez Suspension Therapy Pack 6 x 1 ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069200707", "ndc_label_name": "Beqvez Suspension Therapy Pack 7 x 1 ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069200717", "ndc_label_name": "Beqvez Suspension Therapy Pack 7 x 1 ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63833082502", "ndc_label_name": "Berinert KIT 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43538097160", "ndc_label_name": "Beser Kit 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208044605", "ndc_label_name": "Besivance SUSPENSION 0.6 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569625500", "ndc_label_name": "Besivance Suspension 0.6 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118999305", "ndc_label_name": "Besivance SUSPENSION 0.6 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071152905", "ndc_label_name": "Besivance SUSPENSION 0.6 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090124100", "ndc_label_name": "Besivance Suspension 0.6 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00008010001", "ndc_label_name": "Besponsa Solution Reconstituted 0.9 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "73536050001", "ndc_label_name": "Besremi Solution Prefilled Syringe 500 MCG/ML Subcutaneous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00536490201", "ndc_label_name": "Beta Carotene Capsule 25000 UNIT Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845078001", "ndc_label_name": "Beta Carotene CAPSULE 25000 UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629010302", "ndc_label_name": "Beta Carotene CAPSULE 25000 UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "31604001782", "ndc_label_name": "Beta Carotene CAPSULE 25000 UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917003955", "ndc_label_name": "Beta Carotene CAPSULE 25000 UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312001220", "ndc_label_name": "Beta Carotene Capsule 25000 UNIT Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904431560", "ndc_label_name": "Beta Carotene CAPSULE 25000 UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "48107004906", "ndc_label_name": "Beta Carotene Capsule 25000 UNIT Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917003956", "ndc_label_name": "Beta Carotene CAPSULE 25000 UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292055524", "ndc_label_name": "Beta Carotene CAPSULE 25000 UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40986001759", "ndc_label_name": "Beta Carotene CAPSULE 25000 UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54868102501", "ndc_label_name": "Beta Carotene CAPSULE 25000 UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "62295301802", "ndc_label_name": "Betamethasone Combo Suspension 6 (3-3) MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115147256", "ndc_label_name": "Betamethasone Dipropionate Aug CREAM 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115147252", "ndc_label_name": "Betamethasone Dipropionate Aug CREAM 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672131001", "ndc_label_name": "Betamethasone Dipropionate Aug CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090327000", "ndc_label_name": "Betamethasone Dipropionate Aug Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802037635", "ndc_label_name": "Betamethasone Dipropionate Aug CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959012450", "ndc_label_name": "Betamethasone Dipropionate Aug Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026550", "ndc_label_name": "Betamethasone Dipropionate Aug CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462029052", "ndc_label_name": "Betamethasone Dipropionate Aug Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569619700", "ndc_label_name": "Betamethasone Dipropionate Aug Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026515", "ndc_label_name": "Betamethasone Dipropionate Aug CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569661800", "ndc_label_name": "Betamethasone Dipropionate Aug Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672131003", "ndc_label_name": "Betamethasone Dipropionate Aug CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462029017", "ndc_label_name": "Betamethasone Dipropionate Aug Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788724105", "ndc_label_name": "Betamethasone Dipropionate Aug Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802037632", "ndc_label_name": "Betamethasone Dipropionate Aug CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205027515", "ndc_label_name": "Betamethasone Dipropionate Aug Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217004201", "ndc_label_name": "Betamethasone Dipropionate Aug Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69499032805", "ndc_label_name": "Betamethasone Dipropionate Aug GEL 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999075715", "ndc_label_name": "Betamethasone Dipropionate Aug GEL 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672130901", "ndc_label_name": "Betamethasone Dipropionate Aug GEL 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356064115", "ndc_label_name": "Betamethasone Dipropionate Aug GEL 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672130903", "ndc_label_name": "Betamethasone Dipropionate Aug GEL 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52565002359", "ndc_label_name": "Betamethasone Dipropionate Aug Lotion 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026760", "ndc_label_name": "Betamethasone Dipropionate Aug LOTION 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61748048030", "ndc_label_name": "Betamethasone Dipropionate Aug Lotion 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026730", "ndc_label_name": "Betamethasone Dipropionate Aug LOTION 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672134003", "ndc_label_name": "Betamethasone Dipropionate Aug LOTION 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61748048060", "ndc_label_name": "Betamethasone Dipropionate Aug Lotion 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52565002329", "ndc_label_name": "Betamethasone Dipropionate Aug Lotion 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672134004", "ndc_label_name": "Betamethasone Dipropionate Aug LOTION 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118999506", "ndc_label_name": "Betamethasone Dipropionate Aug LOTION 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118999503", "ndc_label_name": "Betamethasone Dipropionate Aug LOTION 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993089749", "ndc_label_name": "Betamethasone Dipropionate Aug Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180094701", "ndc_label_name": "Betamethasone Dipropionate Aug Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026815", "ndc_label_name": "Betamethasone Dipropionate Aug Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168026850", "ndc_label_name": "Betamethasone Dipropionate Aug Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472038215", "ndc_label_name": "Betamethasone Dipropionate Aug OINTMENT 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472038245", "ndc_label_name": "Betamethasone Dipropionate Aug OINTMENT 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52565001915", "ndc_label_name": "Betamethasone Dipropionate Aug Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180094702", "ndc_label_name": "Betamethasone Dipropionate Aug Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52565001951", "ndc_label_name": "Betamethasone Dipropionate Aug Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993089715", "ndc_label_name": "Betamethasone Dipropionate Aug Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713065915", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472038015", "ndc_label_name": "Betamethasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090327600", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168005515", "ndc_label_name": "Betamethasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569255600", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714099601", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714099602", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168005546", "ndc_label_name": "Betamethasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713065937", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472038045", "ndc_label_name": "Betamethasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672127406", "ndc_label_name": "Betamethasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090037300", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002094163", "ndc_label_name": "Betamethasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261059501", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002094167", "ndc_label_name": "Betamethasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713075937", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710123301", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713075915", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710123304", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672127401", "ndc_label_name": "Betamethasone Dipropionate CREAM 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090183900", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959072115", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261072901", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959072145", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999022215", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569111300", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090218200", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407027315", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407027345", "ndc_label_name": "Betamethasone Dipropionate Cream 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168005760", "ndc_label_name": "Betamethasone Dipropionate LOTION 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713072853", "ndc_label_name": "Betamethasone Dipropionate Lotion 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802002146", "ndc_label_name": "Betamethasone Dipropionate LOTION 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713080753", "ndc_label_name": "Betamethasone Dipropionate LOTION 0.05 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61748047560", "ndc_label_name": "Betamethasone Dipropionate Lotion 0.05 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267129601", "ndc_label_name": "Betamethasone Dipropionate OINTMENT 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959096250", "ndc_label_name": "Betamethasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168005646", "ndc_label_name": "Betamethasone Dipropionate OINTMENT 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168005615", "ndc_label_name": "Betamethasone Dipropionate OINTMENT 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090023600", "ndc_label_name": "Betamethasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217002901", "ndc_label_name": "Betamethasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472038115", "ndc_label_name": "Betamethasone Dipropionate OINTMENT 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356049615", "ndc_label_name": "Betamethasone Dipropionate OINTMENT 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002072367", "ndc_label_name": "Betamethasone Dipropionate OINTMENT 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002072363", "ndc_label_name": "Betamethasone Dipropionate OINTMENT 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217010401", "ndc_label_name": "Betamethasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569111400", "ndc_label_name": "Betamethasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472038145", "ndc_label_name": "Betamethasone Dipropionate OINTMENT 0.05 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788694704", "ndc_label_name": "Betamethasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959026200", "ndc_label_name": "Betamethasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959026215", "ndc_label_name": "Betamethasone Dipropionate Ointment 0.05 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71283062002", "ndc_label_name": "Betamethasone Sod Phos & Acet Suspension 6 (3-3) MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517072001", "ndc_label_name": "Betamethasone Sod Phos & Acet SUSPENSION 6 (3-3) MG/ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517079101", "ndc_label_name": "Betamethasone Sod Phos & Acet Suspension 6 (3-3) MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517079901", "ndc_label_name": "Betamethasone Sod Phos & Acet Suspension 6 (3-3) MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51754506001", "ndc_label_name": "Betamethasone Sod Phos & Acet Suspension 6 (3-3) MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518050600", "ndc_label_name": "Betamethasone Sod Phos & Acet Suspension 6 (3-3) MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518295200", "ndc_label_name": "Betamethasone Sod Phos & Acet Suspension 6 (3-3) MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168004046", "ndc_label_name": "Betamethasone Valerate CREAM 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090164700", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472037045", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261086301", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472037015", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090023700", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168004015", "ndc_label_name": "Betamethasone Valerate CREAM 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267098415", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713032637", "ndc_label_name": "Betamethasone Valerate CREAM 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959026301", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090030901", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090313401", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039801", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205004015", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713032615", "ndc_label_name": "Betamethasone Valerate CREAM 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959026300", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672126906", "ndc_label_name": "Betamethasone Valerate CREAM 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002092163", "ndc_label_name": "Betamethasone Valerate CREAM 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904077645", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788731201", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788731204", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672126901", "ndc_label_name": "Betamethasone Valerate CREAM 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002092167", "ndc_label_name": "Betamethasone Valerate CREAM 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569111500", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569187301", "ndc_label_name": "Betamethasone Valerate Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378818099", "ndc_label_name": "Betamethasone Valerate Foam 0.12 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802005301", "ndc_label_name": "Betamethasone Valerate FOAM 0.12 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672418803", "ndc_label_name": "Betamethasone Valerate FOAM 0.12 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672418807", "ndc_label_name": "Betamethasone Valerate FOAM 0.12 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378818050", "ndc_label_name": "Betamethasone Valerate Foam 0.12 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742031501", "ndc_label_name": "Betamethasone Valerate Foam 0.12 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802005302", "ndc_label_name": "Betamethasone Valerate FOAM 0.12 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742031550", "ndc_label_name": "Betamethasone Valerate Foam 0.12 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118993505", "ndc_label_name": "Betamethasone Valerate FOAM 0.12 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569187401", "ndc_label_name": "Betamethasone Valerate Lotion 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959024303", "ndc_label_name": "Betamethasone Valerate Lotion 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168004160", "ndc_label_name": "Betamethasone Valerate LOTION 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54879000460", "ndc_label_name": "Betamethasone Valerate LOTION 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168003346", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168003315", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713032715", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788739701", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472037115", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002084563", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713032737", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788739704", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569079300", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00472037145", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788739703", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205036415", "ndc_label_name": "Betamethasone Valerate Ointment 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70515011906", "ndc_label_name": "Betapace AF TABLET 120 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419011906", "ndc_label_name": "Betapace AF Tablet 120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419011606", "ndc_label_name": "Betapace AF Tablet 160 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70515011606", "ndc_label_name": "Betapace AF TABLET 160 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70515011506", "ndc_label_name": "Betapace AF TABLET 80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868442300", "ndc_label_name": "Betapace AF TABLET 80 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868442301", "ndc_label_name": "Betapace AF TABLET 80 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419010910", "ndc_label_name": "Betapace Tablet 120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70515010910", "ndc_label_name": "Betapace TABLET 120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70515010610", "ndc_label_name": "Betapace TABLET 160 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419010610", "ndc_label_name": "Betapace Tablet 160 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70515010510", "ndc_label_name": "Betapace TABLET 80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419052335", "ndc_label_name": "Betaseron KIT 0.3 MG Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419052435", "ndc_label_name": "Betaseron KIT 0.3 MG Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419052309", "ndc_label_name": "Betaseron KIT 0.3 MG Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419052401", "ndc_label_name": "Betaseron KIT 0.3 MG Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "17478070510", "ndc_label_name": "Betaxolol HCl Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314024503", "ndc_label_name": "Betaxolol HCl Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314024501", "ndc_label_name": "Betaxolol HCl Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478070511", "ndc_label_name": "Betaxolol HCl Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314024502", "ndc_label_name": "Betaxolol HCl Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10135062301", "ndc_label_name": "Betaxolol HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10702001301", "ndc_label_name": "Betaxolol HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429075301", "ndc_label_name": "Betaxolol HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24658070001", "ndc_label_name": "Betaxolol HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806003801", "ndc_label_name": "Betaxolol HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10135062401", "ndc_label_name": "Betaxolol HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24658070101", "ndc_label_name": "Betaxolol HCl TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429075401", "ndc_label_name": "Betaxolol HCl Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806003901", "ndc_label_name": "Betaxolol HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10702001401", "ndc_label_name": "Betaxolol HCl TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980016101", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832051100", "ndc_label_name": "Bethanechol Chloride TABLET 10 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335084601", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527134001", "ndc_label_name": "Bethanechol Chloride TABLET 10 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832051101", "ndc_label_name": "Bethanechol Chloride TABLET 10 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10135051601", "ndc_label_name": "Bethanechol Chloride TABLET 10 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084036501", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53746057201", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084036511", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687068901", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832051189", "ndc_label_name": "Bethanechol Chloride TABLET 10 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629929301", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135075612", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51293064601", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687068911", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629202301", "ndc_label_name": "Bethanechol Chloride Tablet 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162057210", "ndc_label_name": "Bethanechol Chloride TABLET 10 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527135601", "ndc_label_name": "Bethanechol Chloride TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904617861", "ndc_label_name": "Bethanechol Chloride Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980016201", "ndc_label_name": "Bethanechol Chloride Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268011415", "ndc_label_name": "Bethanechol Chloride Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832051200", "ndc_label_name": "Bethanechol Chloride TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084070401", "ndc_label_name": "Bethanechol Chloride Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832051201", "ndc_label_name": "Bethanechol Chloride TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268011411", "ndc_label_name": "Bethanechol Chloride Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50111032501", "ndc_label_name": "Bethanechol Chloride Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162057310", "ndc_label_name": "Bethanechol Chloride TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084070411", "ndc_label_name": "Bethanechol Chloride Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53746057101", "ndc_label_name": "Bethanechol Chloride Tablet 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51293064501", "ndc_label_name": "Bethanechol Chloride Tablet 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832051000", "ndc_label_name": "Bethanechol Chloride TABLET 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527133201", "ndc_label_name": "Bethanechol Chloride TABLET 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10135051501", "ndc_label_name": "Bethanechol Chloride TABLET 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980016001", "ndc_label_name": "Bethanechol Chloride Tablet 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135075590", "ndc_label_name": "Bethanechol Chloride Tablet 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629202201", "ndc_label_name": "Bethanechol Chloride Tablet 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162057110", "ndc_label_name": "Bethanechol Chloride TABLET 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832051301", "ndc_label_name": "Bethanechol Chloride TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832051300", "ndc_label_name": "Bethanechol Chloride TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527132901", "ndc_label_name": "Bethanechol Chloride TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50111032601", "ndc_label_name": "Bethanechol Chloride Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980016301", "ndc_label_name": "Bethanechol Chloride Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162057410", "ndc_label_name": "Bethanechol Chloride TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10122082004", "ndc_label_name": "Bethkis Nebulization Solution 300 MG/4ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10122082028", "ndc_label_name": "Bethkis Nebulization Solution 300 MG/4ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10122082056", "ndc_label_name": "Bethkis Nebulization Solution 300 MG/4ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "82584000105", "ndc_label_name": "Betimol Solution 0.25 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76478000105", "ndc_label_name": "Betimol SOLUTION 0.25 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76478000210", "ndc_label_name": "Betimol Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76478000205", "ndc_label_name": "Betimol Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82584000205", "ndc_label_name": "Betimol Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76478000215", "ndc_label_name": "Betimol Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82584000215", "ndc_label_name": "Betimol Solution 0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00065024615", "ndc_label_name": "Betoptic-S Suspension 0.25 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00065024610", "ndc_label_name": "Betoptic-S Suspension 0.25 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00310460012", "ndc_label_name": "Bevespi Aerosphere Aerosol 9-4.8 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310460039", "ndc_label_name": "Bevespi Aerosphere Aerosol 9-4.8 MCG/ACT Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69853020201", "ndc_label_name": "Bevyxxa Capsule 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407091890", "ndc_label_name": "Bexagliflozin Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407091830", "ndc_label_name": "Bexagliflozin Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407082630", "ndc_label_name": "Bexagliflozin Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407082690", "ndc_label_name": "Bexagliflozin Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419040703", "ndc_label_name": "Beyaz TABLET 3-0.02-0.451 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419040701", "ndc_label_name": "Beyaz TABLET 3-0.02-0.451 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714081601", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41616048583", "ndc_label_name": "Bicalutamide TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714057102", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093022056", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291016850", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904601946", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093022001", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714057101", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335048583", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429017730", "ndc_label_name": "Bicalutamide TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729002301", "ndc_label_name": "Bicalutamide TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781540931", "ndc_label_name": "Bicalutamide TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429017705", "ndc_label_name": "Bicalutamide TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729002310", "ndc_label_name": "Bicalutamide TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378701793", "ndc_label_name": "Bicalutamide TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714081602", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335048588", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429022605", "ndc_label_name": "Bicalutamide TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505264201", "ndc_label_name": "Bicalutamide TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41616048588", "ndc_label_name": "Bicalutamide TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781540901", "ndc_label_name": "Bicalutamide TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62175013232", "ndc_label_name": "Bicalutamide TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291016830", "ndc_label_name": "Bicalutamide Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505264203", "ndc_label_name": "Bicalutamide TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429017701", "ndc_label_name": "Bicalutamide TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429022630", "ndc_label_name": "Bicalutamide TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60793060202", "ndc_label_name": "Bicillin C-R 900/300 SUSPENSION 900000-300000 UNIT/2ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60793060210", "ndc_label_name": "Bicillin C-R 900/300 SUSPENSION 900000-300000 UNIT/2ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60793060102", "ndc_label_name": "Bicillin C-R SUSPENSION 1200000 UNIT/2ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60793060110", "ndc_label_name": "Bicillin C-R SUSPENSION 1200000 UNIT/2ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60793060010", "ndc_label_name": "Bicillin C-R SUSPENSION 1200000 UNIT/2ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60793060002", "ndc_label_name": "Bicillin C-R SUSPENSION 1200000 UNIT/2ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868246600", "ndc_label_name": "Bicillin L-A SUSPENSION 2400000 UNIT/4ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60793070204", "ndc_label_name": "Bicillin L-A Suspension Prefilled Syringe 2400000 UNIT/4ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60793070210", "ndc_label_name": "Bicillin L-A Suspension Prefilled Syringe 2400000 UNIT/4ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60793070001", "ndc_label_name": "Bicillin L-A Suspension Prefilled Syringe 600000 UNIT/ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60793070010", "ndc_label_name": "Bicillin L-A Suspension Prefilled Syringe 600000 UNIT/ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569587600", "ndc_label_name": "Bicillin L-A Suspension Prefilled Syringe 600000 UNIT/ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155026141", "ndc_label_name": "BiCNU Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338001018", "ndc_label_name": "BiDil Tablet 20-37.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "48107005150", "ndc_label_name": "Big 100 Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68308075130", "ndc_label_name": "Bijuva Capsule 0.5-100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50261021130", "ndc_label_name": "Bijuva Capsule 1-100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61958250501", "ndc_label_name": "Biktarvy Tablet 30-120-15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61958250101", "ndc_label_name": "Biktarvy TABLET 50-200-25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70069040301", "ndc_label_name": "Bimatoprost Solution 0.03 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180042901", "ndc_label_name": "Bimatoprost Solution 0.03 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332050705", "ndc_label_name": "Bimatoprost Solution 0.03 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180042903", "ndc_label_name": "Bimatoprost Solution 0.03 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332050725", "ndc_label_name": "Bimatoprost Solution 0.03 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505058304", "ndc_label_name": "Bimatoprost Solution 0.03 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505058301", "ndc_label_name": "Bimatoprost Solution 0.03 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180042902", "ndc_label_name": "Bimatoprost Solution 0.03 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069040101", "ndc_label_name": "Bimatoprost Solution 0.03 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069040201", "ndc_label_name": "Bimatoprost Solution 0.03 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50474078184", "ndc_label_name": "Bimzelx Solution Auto-Injector 160 MG/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474078185", "ndc_label_name": "Bimzelx Solution Auto-Injector 160 MG/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474078079", "ndc_label_name": "Bimzelx Solution Prefilled Syringe 160 MG/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474078078", "ndc_label_name": "Bimzelx Solution Prefilled Syringe 160 MG/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11877001133", "ndc_label_name": "BinaxNOW COVID-19 Ag Home Test Kit In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11877001140", "ndc_label_name": "BinaxNOW COVID-19 Ag Home Test Kit In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "45737040860", "ndc_label_name": "Biocel TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00065041928", "ndc_label_name": "Bion Tears PF Solution 0.1-0.3 % Ophthalmic", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "59519000239", "ndc_label_name": "BioTel Care Blood Glucose Kit w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "59519000201", "ndc_label_name": "BioTel Care Test Strips Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "74312013430", "ndc_label_name": "Biotin CAPSULE 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "81131011147", "ndc_label_name": "Biotin CAPSULE 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800015193", "ndc_label_name": "Biotin CAPSULE 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629091040", "ndc_label_name": "Biotin CAPSULE 5000 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205054472", "ndc_label_name": "Biotin Capsule 5000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "31604002716", "ndc_label_name": "Biotin CAPSULE 5000 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54022107502", "ndc_label_name": "Biotin Forte Tablet 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54022107501", "ndc_label_name": "Biotin Forte TABLET 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985027116", "ndc_label_name": "Biotin Maximum Strength CAPSULE 5000 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629398501", "ndc_label_name": "Biotin TABLET 1000 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312007961", "ndc_label_name": "Biotin TABLET 1000 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917009900", "ndc_label_name": "Biotin TABLET 1000 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "30768060730", "ndc_label_name": "Biotin Tablet 1000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35046000188", "ndc_label_name": "Biotin Tablet 1000 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10006070048", "ndc_label_name": "Biotin Tablet 300 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904543360", "ndc_label_name": "Biotin Tablet 300 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "48107004908", "ndc_label_name": "Biotin Tablet 300 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00182406001", "ndc_label_name": "Biotin TABLET 300 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312002760", "ndc_label_name": "Biotin Tablet 300 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536665901", "ndc_label_name": "Biotin Tablet 300 MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10542009512", "ndc_label_name": "Biotin TABLET 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917010715", "ndc_label_name": "Biotin TABLET 5000 MCG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50742028313", "ndc_label_name": "Bis Subcit-Metronid-Tetracyc Capsule 140-125-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61269038512", "ndc_label_name": "Bis Subcit-Metronid-Tetracyc Capsule 140-125-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904674860", "ndc_label_name": "Bisacodyl EC Tablet Delayed Release 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904674817", "ndc_label_name": "Bisacodyl EC Tablet Delayed Release 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904640761", "ndc_label_name": "Bisacodyl EC TABLET DELAYED RELEASE 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483000301", "ndc_label_name": "Bisacodyl EC TABLET DELAYED RELEASE 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904792780", "ndc_label_name": "Bisacodyl EC Tablet Delayed Release 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904674880", "ndc_label_name": "Bisacodyl EC Tablet Delayed Release 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205012863", "ndc_label_name": "Bisacodyl EC Tablet Delayed Release 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904792717", "ndc_label_name": "Bisacodyl EC Tablet Delayed Release 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904792760", "ndc_label_name": "Bisacodyl EC Tablet Delayed Release 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49483000310", "ndc_label_name": "Bisacodyl EC TABLET DELAYED RELEASE 5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00574705012", "ndc_label_name": "Bisacodyl SUPPOSITORY 10 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536123801", "ndc_label_name": "Bisacodyl Suppository 10 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00574705050", "ndc_label_name": "Bisacodyl SUPPOSITORY 10 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904698160", "ndc_label_name": "Bisacodyl Suppository 10 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904698112", "ndc_label_name": "Bisacodyl Suppository 10 MG Rectal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904131309", "ndc_label_name": "Bismatrol Suspension 262 MG/15ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904131546", "ndc_label_name": "Bismatrol Tablet Chewable 262 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49884015124", "ndc_label_name": "Bismuth/Metronidaz/Tetracyclin Capsule 140-125-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884015154", "ndc_label_name": "Bismuth/Metronidaz/Tetracyclin Capsule 140-125-125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52817027110", "ndc_label_name": "Bisoprolol Fumarate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185077430", "ndc_label_name": "Bisoprolol Fumarate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862008701", "ndc_label_name": "Bisoprolol Fumarate TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185077401", "ndc_label_name": "Bisoprolol Fumarate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300012701", "ndc_label_name": "Bisoprolol Fumarate TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378052401", "ndc_label_name": "Bisoprolol Fumarate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093527156", "ndc_label_name": "Bisoprolol Fumarate TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52817027130", "ndc_label_name": "Bisoprolol Fumarate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300012713", "ndc_label_name": "Bisoprolol Fumarate TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862008730", "ndc_label_name": "Bisoprolol Fumarate TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378052493", "ndc_label_name": "Bisoprolol Fumarate Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862008601", "ndc_label_name": "Bisoprolol Fumarate TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378052301", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378052393", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185077101", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788677509", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300012613", "ndc_label_name": "Bisoprolol Fumarate TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185077130", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52817027030", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999086600", "ndc_label_name": "Bisoprolol Fumarate TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084048721", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187087190", "ndc_label_name": "Bisoprolol Fumarate TABLET 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300012601", "ndc_label_name": "Bisoprolol Fumarate TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52817027010", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788677501", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862008630", "ndc_label_name": "Bisoprolol Fumarate TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084048711", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919078790", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788677506", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788677503", "ndc_label_name": "Bisoprolol Fumarate Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959024130", "ndc_label_name": "Bisoprolol-hydroCHLOROthiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300018913", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 10-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090079900", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300018901", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 10-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300018905", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 10-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093324356", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185070701", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185070705", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063013430", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378050501", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185070730", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063013490", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378050505", "ndc_label_name": "Bisoprolol-hydroCHLOROthiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569541901", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569541900", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629407501", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 10-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090079600", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185070101", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378050101", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378050110", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300018701", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 2.5-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185070105", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093324101", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544017330", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300018713", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 2.5-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063013590", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185070130", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629167401", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569541701", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300018705", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 2.5-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569541700", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 2.5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185070401", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185070430", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093324201", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185070405", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959033710", "ndc_label_name": "Bisoprolol-hydroCHLOROthiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788688003", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090078902", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300018813", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 5-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378050301", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300018801", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 5-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261091830", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378050310", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289063030", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 5-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959033730", "ndc_label_name": "Bisoprolol-hydroCHLOROthiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788688001", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090078900", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300018805", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 5-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569540402", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261091860", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569540400", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289063090", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide TABLET 5-6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629407201", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788688006", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569540401", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788688009", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788688002", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261091890", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335059501", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864078430", "ndc_label_name": "Bisoprolol-Hydrochlorothiazide Tablet 5-6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59730650301", "ndc_label_name": "Bivigam Solution 10 GM/100ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59730650201", "ndc_label_name": "Bivigam Solution 5 GM/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61703033218", "ndc_label_name": "Bleomycin Sulfate SOLUTION RECONSTITUTED 15 UNIT INJECTION", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288010610", "ndc_label_name": "Bleomycin Sulfate Solution Reconstituted 15 UNIT Injection", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703315401", "ndc_label_name": "Bleomycin Sulfate Solution Reconstituted 15 UNIT Injection", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409033220", "ndc_label_name": "Bleomycin Sulfate Solution Reconstituted 15 UNIT Injection", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323013610", "ndc_label_name": "Bleomycin Sulfate SOLUTION RECONSTITUTED 15 UNIT INJECTION", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143924001", "ndc_label_name": "Bleomycin Sulfate Solution Reconstituted 15 UNIT Injection", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714088601", "ndc_label_name": "Bleomycin Sulfate Solution Reconstituted 15 UNIT Injection", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409032320", "ndc_label_name": "Bleomycin Sulfate Solution Reconstituted 30 UNIT Injection", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61703032322", "ndc_label_name": "Bleomycin Sulfate SOLUTION RECONSTITUTED 30 UNIT INJECTION", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143924101", "ndc_label_name": "Bleomycin Sulfate Solution Reconstituted 30 UNIT Injection", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703315501", "ndc_label_name": "Bleomycin Sulfate Solution Reconstituted 30 UNIT Injection", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288010720", "ndc_label_name": "Bleomycin Sulfate Solution Reconstituted 30 UNIT Injection", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714090801", "ndc_label_name": "Bleomycin Sulfate Solution Reconstituted 30 UNIT Injection", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323013720", "ndc_label_name": "Bleomycin Sulfate SOLUTION RECONSTITUTED 30 UNIT INJECTION", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959027200", "ndc_label_name": "Bleph-10 Solution 10 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959027201", "ndc_label_name": "Bleph-10 Solution 10 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "11980001105", "ndc_label_name": "Bleph-10 Solution 10 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023031304", "ndc_label_name": "Blephamide S.O.P. Ointment 10-0.2 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959027603", "ndc_label_name": "Blephamide S.O.P. Ointment 10-0.2 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569086100", "ndc_label_name": "Blephamide S.O.P. Ointment 10-0.2 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55513016001", "ndc_label_name": "Blincyto SOLUTION RECONSTITUTED 35 MCG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086413", "ndc_label_name": "Blisovi 24 Fe Tablet 1-20 MG-MCG(24) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086471", "ndc_label_name": "Blisovi 24 Fe Tablet 1-20 MG-MCG(24) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086473", "ndc_label_name": "Blisovi 24 Fe Tablet 1-20 MG-MCG(24) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086411", "ndc_label_name": "Blisovi 24 Fe Tablet 1-20 MG-MCG(24) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086673", "ndc_label_name": "Blisovi Fe 1.5/30 Tablet 1.5-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086611", "ndc_label_name": "Blisovi Fe 1.5/30 Tablet 1.5-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086613", "ndc_label_name": "Blisovi Fe 1.5/30 Tablet 1.5-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086671", "ndc_label_name": "Blisovi Fe 1.5/30 Tablet 1.5-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086571", "ndc_label_name": "Blisovi FE 1/20 Tablet 1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086573", "ndc_label_name": "Blisovi FE 1/20 Tablet 1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086511", "ndc_label_name": "Blisovi FE 1/20 Tablet 1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180086513", "ndc_label_name": "Blisovi FE 1/20 Tablet 1-20 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "36800036743", "ndc_label_name": "Blood Glucose Monitor System KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295012209", "ndc_label_name": "Blood Glucose Monitor System KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295011715", "ndc_label_name": "Blood Glucose Monitor System KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295012914", "ndc_label_name": "Blood Glucose Monitor System Kit w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08539391000", "ndc_label_name": "Blood Glucose Monitoring 333 Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800036745", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800036740", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917005075", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917003182", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917005076", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295012211", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800036741", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295012210", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295011717", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800036742", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295012915", "ndc_label_name": "Blood Glucose Test Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295011716", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800036744", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295012916", "ndc_label_name": "Blood Glucose Test Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295012208", "ndc_label_name": "Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295012917", "ndc_label_name": "Blood Glucose Test Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08539391502", "ndc_label_name": "Blood Glucose Test Strips 333 Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673000021", "ndc_label_name": "Blood Pressure KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673000019", "ndc_label_name": "Blood Pressure KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917018375", "ndc_label_name": "Blood Pressure Kit DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38703001320", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205000503", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38703001030", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917006877", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38703001000", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38703001430", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38703001440", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205000603", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38703001447", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38703001600", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38703001750", "ndc_label_name": "Blood Pressure Kit KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917010045", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917005174", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917008198", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917005331", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917005175", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076561", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917003095", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917011208", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319003025", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917008201", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319002693", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917008197", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917005176", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001091", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917008196", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319003026", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076590", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917011211", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319003028", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917010219", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "93764060137", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001097", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917008200", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076211", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001083", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076571", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076220", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "42632000404", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "93764060138", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001140", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917011210", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076290", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001093", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205000703", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076820", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "73796000609", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "40986001168", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "40986001953", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076830", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076501", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "40986002152", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "73796079090", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001060", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "73796004322", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "73796065036", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "73796078000", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001094", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076520", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "73796071142", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "82891038801", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001092", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "22319076551", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "93764060062", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "93764060155", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "93764060047", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001085", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001095", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "93764060213", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "93764081767", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673004021", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673001100", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "93764060158", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673011313", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38673011306", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "93764060157", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "40986001167", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "40986001169", "ndc_label_name": "Blood Pressure Monitor", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "73796027104", "ndc_label_name": "Blood Pressure Monitor 3 DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917018336", "ndc_label_name": "Blood Pressure Monitor Automat DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295012184", "ndc_label_name": "Blood Pressure Monitor Automat Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "42167008930", "ndc_label_name": "Blood Pressure Monitor Automat Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917018340", "ndc_label_name": "Blood Pressure Monitor Deluxe KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917018337", "ndc_label_name": "Blood Pressure Monitor Deluxe KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800033409", "ndc_label_name": "Blood Pressure Monitor Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "82891037200", "ndc_label_name": "Blood Pressure Monitor DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800033411", "ndc_label_name": "Blood Pressure Monitor Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800033410", "ndc_label_name": "Blood Pressure Monitor Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "42632002121", "ndc_label_name": "Blood Pressure Monitor DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917014487", "ndc_label_name": "Blood Pressure Monitor/Arm DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917014484", "ndc_label_name": "Blood Pressure Monitor/Arm DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917018339", "ndc_label_name": "Blood Pressure Monitor/Arm DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917014485", "ndc_label_name": "Blood Pressure Monitor/Arm DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "42632001212", "ndc_label_name": "Blood Pressure Monitor/Arm DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917017235", "ndc_label_name": "Blood Pressure Monitor/Prm Arm DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "91237000107", "ndc_label_name": "Blood Pressure Monitor/Wrist DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917014486", "ndc_label_name": "Blood Pressure Monitor/Wrist DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917011213", "ndc_label_name": "Blood Pressure Monitor/Wrist DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917011212", "ndc_label_name": "Blood Pressure Monitor/Wrist DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "96295012187", "ndc_label_name": "Blood Pressure Monitor/Wrist Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917014488", "ndc_label_name": "Blood Pressure Monitor/Wrist DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "40986002583", "ndc_label_name": "Blood Pressure Monitor/Wrist DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11917018338", "ndc_label_name": "Blood Pressure Monitor/Wrist KIT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38703000161", "ndc_label_name": "Blood Pressure Unit", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08496701301", "ndc_label_name": "BluLink Glucose Monitoring Sys Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08496701501", "ndc_label_name": "BluLink Glucose Test Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "11845012065", "ndc_label_name": "Body/Hair/Skin/Nails CAPSULE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00004019109", "ndc_label_name": "Boniva Solution 3 MG/3ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00004018683", "ndc_label_name": "Boniva Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00004018682", "ndc_label_name": "Boniva Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356042303", "ndc_label_name": "Boniva Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55494012060", "ndc_label_name": "Bonjesta Tablet Extended Release 20-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58160084201", "ndc_label_name": "Boostrix Suspension 5-2.5-18.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58160084232", "ndc_label_name": "Boostrix Suspension 5-2.5-18.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569638600", "ndc_label_name": "Boostrix Suspension 5-2.5-18.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58160084211", "ndc_label_name": "Boostrix Suspension 5-2.5-18.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58160084252", "ndc_label_name": "Boostrix Suspension Prefilled Syringe 5-2.5-18.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58160084205", "ndc_label_name": "Boostrix Suspension Prefilled Syringe 5-2.5-18.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58160084234", "ndc_label_name": "Boostrix Suspension Prefilled Syringe 5-2.5-18.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58160084243", "ndc_label_name": "Boostrix Suspension Prefilled Syringe 5-2.5-18.5 LF-MCG/0.5 Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72266024401", "ndc_label_name": "Bortezomib Solution 3.5 MG/1.4ML Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72266024401", "ndc_label_name": "Bortezomib Solution 3.5 MG/1.4ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409170401", "ndc_label_name": "Bortezomib Solution Reconstituted 1 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409170301", "ndc_label_name": "Bortezomib Solution Reconstituted 2.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150033701", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001053436", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143909801", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598042660", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409170001", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "83090000801", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10019099101", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742048401", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001054036", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001054136", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021024410", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72603027001", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860022510", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710141101", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505605004", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72205018301", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722030331", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323082110", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288011810", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323072110", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598086560", "ndc_label_name": "Bortezomib Solution Reconstituted 3.5 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591251260", "ndc_label_name": "Bosentan Tablet 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054052121", "ndc_label_name": "Bosentan Tablet 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335003986", "ndc_label_name": "Bosentan Tablet 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10148012560", "ndc_label_name": "Bosentan Tablet 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162087406", "ndc_label_name": "Bosentan Tablet 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382044714", "ndc_label_name": "Bosentan Tablet 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884005902", "ndc_label_name": "Bosentan Tablet 125 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335003886", "ndc_label_name": "Bosentan Tablet 62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054052021", "ndc_label_name": "Bosentan Tablet 62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162087306", "ndc_label_name": "Bosentan Tablet 62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10148062560", "ndc_label_name": "Bosentan Tablet 62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591251160", "ndc_label_name": "Bosentan Tablet 62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382044614", "ndc_label_name": "Bosentan Tablet 62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884005802", "ndc_label_name": "Bosentan Tablet 62.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069101415", "ndc_label_name": "Bosulif Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069050430", "ndc_label_name": "Bosulif Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069013501", "ndc_label_name": "Bosulif Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069019301", "ndc_label_name": "Bosulif Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069013601", "ndc_label_name": "Bosulif Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00023923201", "ndc_label_name": "Botox Cosmetic SOLUTION RECONSTITUTED 100 UNIT Intramuscular", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023391950", "ndc_label_name": "Botox Cosmetic SOLUTION RECONSTITUTED 50 UNIT Intramuscular", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00023114501", "ndc_label_name": "Botox SOLUTION RECONSTITUTED 100 UNIT INJECTION", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00023114502", "ndc_label_name": "Botox Solution Reconstituted 100 UNIT Injection", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00023392102", "ndc_label_name": "Botox SOLUTION RECONSTITUTED 200 UNIT INJECTION", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42192010406", "ndc_label_name": "BP 10-1 EMULSION 10-1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42192010316", "ndc_label_name": "BP Cleansing Wash Emulsion 10-4 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42192012560", "ndc_label_name": "BPO Foaming Cloths 6 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42192016160", "ndc_label_name": "BPO Foaming Cloths 6 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "76518001008", "ndc_label_name": "BProtected Multi-Vite Liquid Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70255002504", "ndc_label_name": "Braftovi Capsule 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70255002502", "ndc_label_name": "Braftovi Capsule 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70255002501", "ndc_label_name": "Braftovi Capsule 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70255002503", "ndc_label_name": "Braftovi Capsule 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70914003500", "ndc_label_name": "Breathe Ease Humidifier", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70914003330", "ndc_label_name": "Breathe Ease Large Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70914003320", "ndc_label_name": "Breathe Ease Medium Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70914003310", "ndc_label_name": "Breathe Ease Small Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11391030202", "ndc_label_name": "BreatheRite Coll Spacer Infant", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11391030210", "ndc_label_name": "BreatheRite/Large Mask", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11391030110", "ndc_label_name": "BreatheRite/Large Mask", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11391030220", "ndc_label_name": "BreatheRite/Medium Mask", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11391030120", "ndc_label_name": "BreatheRite/Medium Mask", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "82381217401", "ndc_label_name": "Brenzavvy Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82381217402", "ndc_label_name": "Brenzavvy Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00173085914", "ndc_label_name": "Breo Ellipta Aerosol Powder Breath Activated 100-25 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173085910", "ndc_label_name": "Breo Ellipta Aerosol Powder Breath Activated 100-25 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173088210", "ndc_label_name": "Breo Ellipta Aerosol Powder Breath Activated 200-25 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173088214", "ndc_label_name": "Breo Ellipta Aerosol Powder Breath Activated 200-25 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569666500", "ndc_label_name": "Breo Ellipta Aerosol Powder Breath Activated 200-25 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00173091610", "ndc_label_name": "Breo Ellipta Aerosol Powder Breath Activated 50-25 MCG/INH Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10019007587", "ndc_label_name": "Brevibloc in NaCl Solution 2000 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10019066810", "ndc_label_name": "Brevibloc in NaCl Solution 2000 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10019005561", "ndc_label_name": "Brevibloc in NaCl Solution 2500 MG/250ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10019067210", "ndc_label_name": "Brevibloc in NaCl Solution 2500 MG/250ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10019066610", "ndc_label_name": "Brevibloc Premixed DS Solution 2000 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10019067010", "ndc_label_name": "Brevibloc Premixed Solution 2500 MG/250ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10019011501", "ndc_label_name": "Brevibloc SOLUTION 100 MG/10ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10019011539", "ndc_label_name": "Brevibloc SOLUTION 100 MG/10ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10019008501", "ndc_label_name": "Brevibloc SOLUTION 20 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75788011504", "ndc_label_name": "Brexafemme Tablet 150 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73153090001", "ndc_label_name": "Breyanzi Suspension 70000000 CELLS/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "73153090001", "ndc_label_name": "Breyanzi Suspension Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378750332", "ndc_label_name": "Breyna Aerosol 160-4.5 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378750232", "ndc_label_name": "Breyna Aerosol 80-4.5 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310461639", "ndc_label_name": "Breztri Aerosphere Aerosol 160-9-4.8 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310461628", "ndc_label_name": "Breztri Aerosphere Aerosol 160-9-4.8 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310461612", "ndc_label_name": "Breztri Aerosphere Aerosol 160-9-4.8 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462031629", "ndc_label_name": "Briellyn TABLET 0.4-35 MG-MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462031684", "ndc_label_name": "Briellyn Tablet 0.4-35 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00186077660", "ndc_label_name": "Brilinta TABLET 60 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186077708", "ndc_label_name": "Brilinta TABLET 90 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186077739", "ndc_label_name": "Brilinta TABLET 90 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00186077760", "ndc_label_name": "Brilinta TABLET 90 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505057702", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781717775", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781717770", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332074905", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505057703", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505057701", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781717785", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069056601", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332074910", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82182032110", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332074915", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069056801", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069056701", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82182032105", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82182032115", "ndc_label_name": "Brimonidine Tartrate Solution 0.1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569633400", "ndc_label_name": "Brimonidine Tartrate Solution 0.15 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314014410", "ndc_label_name": "Brimonidine Tartrate SOLUTION 0.15 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314014405", "ndc_label_name": "Brimonidine Tartrate SOLUTION 0.15 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314014415", "ndc_label_name": "Brimonidine Tartrate SOLUTION 0.15 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314014310", "ndc_label_name": "Brimonidine Tartrate SOLUTION 0.2 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71921018510", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478071511", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478071510", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208041110", "ndc_label_name": "Brimonidine Tartrate SOLUTION 0.2 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314014305", "ndc_label_name": "Brimonidine Tartrate SOLUTION 0.2 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208041115", "ndc_label_name": "Brimonidine Tartrate SOLUTION 0.2 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090104600", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069023201", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71921018515", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090636800", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478071512", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314014315", "ndc_label_name": "Brimonidine Tartrate SOLUTION 0.2 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208041105", "ndc_label_name": "Brimonidine Tartrate SOLUTION 0.2 % OPHTHALMIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069023301", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069023101", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71921018505", "ndc_label_name": "Brimonidine Tartrate Solution 0.2 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781718685", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832142515", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591242279", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505058902", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832142510", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781718670", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591242226", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591242212", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505058901", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332070605", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069065101", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332070615", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505622500", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832142505", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505622501", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781718675", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332070610", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505058903", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462028132", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71921018805", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462028169", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069065201", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71921018815", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505622502", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162209604", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162209607", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82182045510", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82182045505", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069065301", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82182045515", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71921018810", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162209602", "ndc_label_name": "Brimonidine Tartrate-Timolol Solution 0.2-0.5 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68135081102", "ndc_label_name": "Brineura Kit 2 X 150 MG/5ML", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591212779", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682046410", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629879301", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781601485", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162220104", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574401215", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162220102", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574401210", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682046415", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591212712", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781601470", "ndc_label_name": "Brinzolamide Suspension 1 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54766090753", "ndc_label_name": "Brisdelle Capsule 7.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68968907503", "ndc_label_name": "Brisdelle CAPSULE 7.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73150015006", "ndc_label_name": "Briumvi Solution 150 MG/6ML Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474087015", "ndc_label_name": "Briviact SOLUTION 10 MG/ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474037066", "ndc_label_name": "Briviact TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474077009", "ndc_label_name": "Briviact TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474077066", "ndc_label_name": "Briviact TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474047066", "ndc_label_name": "Briviact TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474047009", "ndc_label_name": "Briviact TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474057009", "ndc_label_name": "Briviact TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474057066", "ndc_label_name": "Briviact TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474067066", "ndc_label_name": "Briviact TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284021601", "ndc_label_name": "Brixadi (Weekly) Solution Prefilled Syringe 16 MG/0.32ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284021691", "ndc_label_name": "Brixadi (Weekly) Solution Prefilled Syringe 16 MG/0.32ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284022401", "ndc_label_name": "Brixadi (Weekly) Solution Prefilled Syringe 24 MG/0.48ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284022491", "ndc_label_name": "Brixadi (Weekly) Solution Prefilled Syringe 24 MG/0.48ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284023201", "ndc_label_name": "Brixadi (Weekly) Solution Prefilled Syringe 32 MG/0.64ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284023291", "ndc_label_name": "Brixadi (Weekly) Solution Prefilled Syringe 32 MG/0.64ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284020801", "ndc_label_name": "Brixadi (Weekly) Solution Prefilled Syringe 8 MG/0.16ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284022891", "ndc_label_name": "Brixadi Solution Prefilled Syringe 128 MG/0.36ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284022801", "ndc_label_name": "Brixadi Solution Prefilled Syringe 128 MG/0.36ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284026491", "ndc_label_name": "Brixadi Solution Prefilled Syringe 64 MG/0.18ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284026401", "ndc_label_name": "Brixadi Solution Prefilled Syringe 64 MG/0.18ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284029601", "ndc_label_name": "Brixadi Solution Prefilled Syringe 96 MG/0.27ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58284029691", "ndc_label_name": "Brixadi Solution Prefilled Syringe 96 MG/0.27ML Subcutaneous", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862078917", "ndc_label_name": "Bromfenac Sodium (Once-Daily) Solution 0.09 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332050817", "ndc_label_name": "Bromfenac Sodium (Once-Daily) Solution 0.09 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180043601", "ndc_label_name": "Bromfenac Sodium (Once-Daily) Solution 0.09 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383024971", "ndc_label_name": "Bromfenac Sodium (Once-Daily) Solution 0.09 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72266014201", "ndc_label_name": "Bromfenac Sodium (Once-Daily) Solution 0.09 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485064971", "ndc_label_name": "Bromfenac Sodium (Once-Daily) Solution 0.09 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62332058303", "ndc_label_name": "Bromfenac Sodium Solution 0.07 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180043302", "ndc_label_name": "Bromfenac Sodium Solution 0.07 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75907009303", "ndc_label_name": "Bromfenac Sodium Solution 0.07 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505100602", "ndc_label_name": "Bromfenac Sodium Solution 0.07 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82260060203", "ndc_label_name": "Bromfenac Sodium Solution 0.07 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180043401", "ndc_label_name": "Bromfenac Sodium Solution 0.075 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49708075541", "ndc_label_name": "Bromfenac Sodium Solution 0.075 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304015801", "ndc_label_name": "Bromocriptine Mesylate CAPSULE 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378709601", "ndc_label_name": "Bromocriptine Mesylate CAPSULE 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382011001", "ndc_label_name": "Bromocriptine Mesylate Capsule 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378709693", "ndc_label_name": "Bromocriptine Mesylate CAPSULE 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382011006", "ndc_label_name": "Bromocriptine Mesylate CAPSULE 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304015830", "ndc_label_name": "Bromocriptine Mesylate CAPSULE 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687028611", "ndc_label_name": "Bromocriptine Mesylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781532501", "ndc_label_name": "Bromocriptine Mesylate TABLET 2.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00574010603", "ndc_label_name": "Bromocriptine Mesylate TABLET 2.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378204201", "ndc_label_name": "Bromocriptine Mesylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781532531", "ndc_label_name": "Bromocriptine Mesylate TABLET 2.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304096201", "ndc_label_name": "Bromocriptine Mesylate TABLET 2.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378204293", "ndc_label_name": "Bromocriptine Mesylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00574010601", "ndc_label_name": "Bromocriptine Mesylate TABLET 2.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687028621", "ndc_label_name": "Bromocriptine Mesylate Tablet 2.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63304096230", "ndc_label_name": "Bromocriptine Mesylate TABLET 2.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49708075441", "ndc_label_name": "BromSite Solution 0.075 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "84639021256", "ndc_label_name": "Bronchitol Capsule 40 MG Inhalation", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10122021214", "ndc_label_name": "Bronchitol Capsule 40 MG Inhalation", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10122021256", "ndc_label_name": "Bronchitol Capsule 40 MG Inhalation", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "84639021214", "ndc_label_name": "Bronchitol Capsule 40 MG Inhalation", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "84639021204", "ndc_label_name": "Bronchitol Tolerance Test Capsule 40 MG Inhalation", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10122021204", "ndc_label_name": "Bronchitol Tolerance Test Capsule 40 MG Inhalation", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63402091130", "ndc_label_name": "Brovana Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63402091101", "ndc_label_name": "Brovana Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63402091164", "ndc_label_name": "Brovana Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63402091104", "ndc_label_name": "Brovana Nebulization Solution 15 MCG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72579001102", "ndc_label_name": "Brukinsa Capsule 80 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187000260", "ndc_label_name": "Bryhali Lotion 0.01 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00187000201", "ndc_label_name": "Bryhali Lotion 0.01 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980025501", "ndc_label_name": "Budesonide CAPSULE DELAYED RELEASE PARTICLES 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862058201", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862058001", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378715505", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378715501", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093744501", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781014601", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00574985510", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079002003", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714082901", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687042195", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884050101", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700059090", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079002001", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429026401", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382072001", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687042125", "ndc_label_name": "Budesonide Capsule Delayed Release Particles 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162077810", "ndc_label_name": "Budesonide CAPSULE DELAYED RELEASE PARTICLES 3 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591251030", "ndc_label_name": "Budesonide ER Tablet Extended Release 24 Hour 9 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407022430", "ndc_label_name": "Budesonide ER Tablet Extended Release 24 Hour 9 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68682030930", "ndc_label_name": "Budesonide ER Tablet Extended Release 24 Hour 9 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802062701", "ndc_label_name": "Budesonide Foam 2 MG Rectal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45802062786", "ndc_label_name": "Budesonide Foam 2 MG Rectal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68682065803", "ndc_label_name": "Budesonide Foam 2 MG/ACT Rectal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68682065802", "ndc_label_name": "Budesonide Foam 2 MG/ACT Rectal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681545", "ndc_label_name": "Budesonide SUSPENSION 0.25 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681573", "ndc_label_name": "Budesonide SUSPENSION 0.25 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681555", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681519", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569655700", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115168774", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788729003", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00487960101", "ndc_label_name": "Budesonide SUSPENSION 0.25 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115168776", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591376730", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097031887", "ndc_label_name": "Budesonide SUSPENSION 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097031886", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00487960130", "ndc_label_name": "Budesonide SUSPENSION 0.25 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781751587", "ndc_label_name": "Budesonide SUSPENSION 0.25 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781751514", "ndc_label_name": "Budesonide SUSPENSION 0.25 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282064038", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788702003", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282064037", "ndc_label_name": "Budesonide Suspension 0.25 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00487970101", "ndc_label_name": "Budesonide SUSPENSION 0.5 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180098430", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681655", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788679603", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681673", "ndc_label_name": "Budesonide SUSPENSION 0.5 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097031986", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115168976", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681619", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00487970130", "ndc_label_name": "Budesonide SUSPENSION 0.5 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282064137", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788376803", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681645", "ndc_label_name": "Budesonide SUSPENSION 0.5 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781751687", "ndc_label_name": "Budesonide SUSPENSION 0.5 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115168974", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687052483", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591376830", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687052479", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781751614", "ndc_label_name": "Budesonide SUSPENSION 0.5 MG/2ML INHALATION", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788731403", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569655800", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282064138", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097031987", "ndc_label_name": "Budesonide SUSPENSION 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180098405", "ndc_label_name": "Budesonide Suspension 0.5 MG/2ML Inhalation", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681745", "ndc_label_name": "Budesonide SUSPENSION 1 MG/2ML INHALATION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681773", "ndc_label_name": "Budesonide SUSPENSION 1 MG/2ML INHALATION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282064237", "ndc_label_name": "Budesonide Suspension 1 MG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282064238", "ndc_label_name": "Budesonide Suspension 1 MG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093681719", "ndc_label_name": "Budesonide SUSPENSION 1 MG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781751787", "ndc_label_name": "Budesonide SUSPENSION 1 MG/2ML INHALATION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097032186", "ndc_label_name": "Budesonide Suspension 1 MG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781751714", "ndc_label_name": "Budesonide SUSPENSION 1 MG/2ML INHALATION", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097032187", "ndc_label_name": "Budesonide SUSPENSION 1 MG/2ML Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00536111248", "ndc_label_name": "Budesonide SUSPENSION 32 MCG/ACT NASAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60505083902", "ndc_label_name": "Budesonide SUSPENSION 32 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11917018320", "ndc_label_name": "Budesonide SUSPENSION 32 MCG/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60505612902", "ndc_label_name": "Budesonide SUSPENSION 32 MCG/ACT NASAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00310737020", "ndc_label_name": "Budesonide-Formoterol Fumarate Aerosol 160-4.5 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310737220", "ndc_label_name": "Budesonide-Formoterol Fumarate Aerosol 80-4.5 MCG/ACT Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "38415000013", "ndc_label_name": "Bullseye Safety Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "38415000015", "ndc_label_name": "Bullseye Safety Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50268013015", "ndc_label_name": "Bumetanide Tablet 0.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832054011", "ndc_label_name": "Bumetanide TABLET 0.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093423201", "ndc_label_name": "Bumetanide Tablet 0.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382052501", "ndc_label_name": "Bumetanide Tablet 0.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185012805", "ndc_label_name": "Bumetanide TABLET 0.5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185012801", "ndc_label_name": "Bumetanide TABLET 0.5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238148901", "ndc_label_name": "Bumetanide TABLET 0.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42799011901", "ndc_label_name": "Bumetanide TABLET 0.5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714083101", "ndc_label_name": "Bumetanide Tablet 0.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "14539070001", "ndc_label_name": "Bumetanide Tablet 0.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714083201", "ndc_label_name": "Bumetanide Tablet 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687038495", "ndc_label_name": "Bumetanide Tablet 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714083202", "ndc_label_name": "Bumetanide Tablet 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093423301", "ndc_label_name": "Bumetanide Tablet 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268013115", "ndc_label_name": "Bumetanide Tablet 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093423310", "ndc_label_name": "Bumetanide Tablet 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185012905", "ndc_label_name": "Bumetanide TABLET 1 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238149005", "ndc_label_name": "Bumetanide TABLET 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42799012002", "ndc_label_name": "Bumetanide TABLET 1 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185012901", "ndc_label_name": "Bumetanide TABLET 1 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382052601", "ndc_label_name": "Bumetanide Tablet 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "14539070101", "ndc_label_name": "Bumetanide Tablet 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832054111", "ndc_label_name": "Bumetanide TABLET 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42799012001", "ndc_label_name": "Bumetanide TABLET 1 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238149001", "ndc_label_name": "Bumetanide TABLET 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687038425", "ndc_label_name": "Bumetanide Tablet 1 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714083302", "ndc_label_name": "Bumetanide Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238149105", "ndc_label_name": "Bumetanide TABLET 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "14539070201", "ndc_label_name": "Bumetanide Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238149101", "ndc_label_name": "Bumetanide TABLET 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382052701", "ndc_label_name": "Bumetanide Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093423401", "ndc_label_name": "Bumetanide Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093423410", "ndc_label_name": "Bumetanide Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185013005", "ndc_label_name": "Bumetanide TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42799012102", "ndc_label_name": "Bumetanide TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714083301", "ndc_label_name": "Bumetanide Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185013001", "ndc_label_name": "Bumetanide TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42799012101", "ndc_label_name": "Bumetanide TABLET 2 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832054211", "ndc_label_name": "Bumetanide TABLET 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268013215", "ndc_label_name": "Bumetanide Tablet 2 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00095300001", "ndc_label_name": "Bupap Tablet 50-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "75987007009", "ndc_label_name": "Buphenyl POWDER 3 GM/TSP ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75987006008", "ndc_label_name": "Buphenyl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59923071705", "ndc_label_name": "Bupivacaine Fisiopharma Solution 2.5 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59923071910", "ndc_label_name": "Bupivacaine Fisiopharma Solution 2.5 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59923072010", "ndc_label_name": "Bupivacaine Fisiopharma Solution 5 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59923071805", "ndc_label_name": "Bupivacaine Fisiopharma Solution 5 MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "81371504003", "ndc_label_name": "Bupivacaine HCl (Bulk) Solution 4760 MG/119ML", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409115902", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.25 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409115910", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.25 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933010", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409115901", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.25 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933001", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933310", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933301", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288072232", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150016830", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.25 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594011501", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409115909", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.25 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409115918", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594011401", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150016710", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.25 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409115919", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594011402", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288072111", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76420001810", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933401", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116218", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288072411", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933410", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933110", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518236000", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933101", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116209", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116202", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.5 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116210", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116201", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.5 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594011702", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116219", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.5 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150016910", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.5 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150017030", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.5 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594011801", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594011701", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518236001", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288072532", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116519", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.75 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933501", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.75 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933201", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.75 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594012001", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.75 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933510", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.75 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594012101", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.75 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143933210", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.75 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116501", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.75 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594012002", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.75 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116518", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.75 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288072711", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.75 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116502", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.75 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288072832", "ndc_label_name": "Bupivacaine HCl (PF) Solution 0.75 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150017110", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.75 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150017230", "ndc_label_name": "Bupivacaine HCl (PF) SOLUTION 0.75 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51552045607", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00395805062", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00395805019", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10695003810", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00395805035", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00395805043", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "46144014110", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51927235800", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71092998403", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "15455698807", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00395805037", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "15455698801", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "15455698802", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49452131301", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49452131305", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62991201404", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82393020811", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "38779052403", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "15455698803", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "15455698804", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "15455698805", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51552045605", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51552045601", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62991201406", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49452131302", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "38779052405", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "15455698806", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "38779052401", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51552045604", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63275999302", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63275999304", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62991201407", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60966022703", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "38779052408", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "38779052409", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "38779052404", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60966032702", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63275999305", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63307006011", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71092998404", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63275999309", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54288120905", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60966012704", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49452131303", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82393020808", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63275999308", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62991201402", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82393020805", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62991201403", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60966042701", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62991201405", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49452131304", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63307006005", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62991201401", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71092998401", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82393020807", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71092998405", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "82393020810", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75839038300", "ndc_label_name": "Bupivacaine HCl Powder", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51552045602", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75840010601", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54288120910", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63307006015", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69589000201", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71092998402", "ndc_label_name": "Bupivacaine HCl POWDER", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69374097005", "ndc_label_name": "Bupivacaine HCl Solution 0.125 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143932810", "ndc_label_name": "Bupivacaine HCl Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069075210", "ndc_label_name": "BUPivacaine HCl Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143932801", "ndc_label_name": "Bupivacaine HCl Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116001", "ndc_label_name": "Bupivacaine HCl SOLUTION 0.25 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288072352", "ndc_label_name": "Bupivacaine HCl Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "81483000300", "ndc_label_name": "BUPivacaine HCl Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116018", "ndc_label_name": "Bupivacaine HCl SOLUTION 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594011601", "ndc_label_name": "Bupivacaine HCl Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069075225", "ndc_label_name": "BUPivacaine HCl Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150024950", "ndc_label_name": "Bupivacaine HCl SOLUTION 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069075201", "ndc_label_name": "BUPivacaine HCl Solution 0.25 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143932901", "ndc_label_name": "Bupivacaine HCl Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069075301", "ndc_label_name": "BUPivacaine HCl Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150025050", "ndc_label_name": "Bupivacaine HCl SOLUTION 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143932910", "ndc_label_name": "Bupivacaine HCl Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116318", "ndc_label_name": "Bupivacaine HCl SOLUTION 0.5 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090451600", "ndc_label_name": "Bupivacaine HCl Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594011901", "ndc_label_name": "Bupivacaine HCl Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "81483000400", "ndc_label_name": "BUPivacaine HCl Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288072652", "ndc_label_name": "Bupivacaine HCl Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069075325", "ndc_label_name": "BUPivacaine HCl Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70069075310", "ndc_label_name": "BUPivacaine HCl Solution 0.5 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116301", "ndc_label_name": "Bupivacaine HCl SOLUTION 0.5 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409116401", "ndc_label_name": "Bupivacaine HCl SOLUTION 0.75 % INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71244033110", "ndc_label_name": "Bupivacaine HCl Solution 312.5 MG/10ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69374097050", "ndc_label_name": "Bupivacaine HCl Solution Prefilled Syringe 0.125 % (50 ML) Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71266916002", "ndc_label_name": "Bupivacaine HCl Solution Prefilled Syringe 0.25 % (10 ML) Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69374099330", "ndc_label_name": "Bupivacaine HCl Solution Prefilled Syringe 0.25 % (30 ML) Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019002301", "ndc_label_name": "Bupivacaine HCl Solution Prefilled Syringe 0.5 % (20 ML) Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019002401", "ndc_label_name": "Bupivacaine HCl Solution Prefilled Syringe 0.5 % (30 ML) Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019002501", "ndc_label_name": "Bupivacaine HCl Solution Prefilled Syringe 0.5 % (60 ML) Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71244013104", "ndc_label_name": "Bupivacaine HCl Solution Prefilled Syringe 125 MG/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71244013108", "ndc_label_name": "Bupivacaine HCl Solution Prefilled Syringe 250 MG/8ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71244013101", "ndc_label_name": "Bupivacaine HCl Solution Prefilled Syringe 312.5 MG/10ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71244013120", "ndc_label_name": "Bupivacaine HCl Solution Prefilled Syringe 625 MG/20ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001201", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.03-0.9 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001407", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.0625-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001402", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.0625-0.9 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001504", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.1-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001502", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.1-0.9 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70092108937", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.125-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70092959140", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.125-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001602", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.125-0.9 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001701", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.15-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001902", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.2-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001901", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.2-0.9 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019002004", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.25-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019002006", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.25-0.9 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019013901", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.375-0.9 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019002201", "ndc_label_name": "Bupivacaine HCl-NaCl Solution 0.5-0.9 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001406", "ndc_label_name": "Bupivacaine HCl-NaCl Solution Prefilled Syringe 0.0625-0.9 % (50 ML) Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001524", "ndc_label_name": "Bupivacaine HCl-NaCl Solution Prefilled Syringe 0.1-0.9 % (50 ML) Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001525", "ndc_label_name": "Bupivacaine HCl-NaCl Solution Prefilled Syringe 0.1-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019001626", "ndc_label_name": "Bupivacaine HCl-NaCl Solution Prefilled Syringe 0.125-0.9 % (50 ML) Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019002019", "ndc_label_name": "Bupivacaine HCl-NaCl Solution Prefilled Syringe 0.25-0.9 % (30 ML) Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70092153946", "ndc_label_name": "Bupivacaine HCl-NaCl Solution Prefilled Syringe 0.25-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70092953946", "ndc_label_name": "Bupivacaine HCl-NaCl Solution Prefilled Syringe 0.25-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019002020", "ndc_label_name": "Bupivacaine HCl-NaCl Solution Prefilled Syringe 0.25-0.9 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019002103", "ndc_label_name": "Bupivacaine HCl-NaCl Solution Prefilled Syringe 0.375-0.9 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71019002205", "ndc_label_name": "Bupivacaine HCl-NaCl Solution Prefilled Syringe 0.5-0.9 % Epidural", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71351002202", "ndc_label_name": "Bupivacaine in Dextrose Solution 0.75-8.25 % Intrathecal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71351002210", "ndc_label_name": "Bupivacaine in Dextrose Solution 0.75-8.25 % Intrathecal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "36000009201", "ndc_label_name": "Bupivacaine in Dextrose Solution 0.75-8.25 % Intrathecal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "36000009210", "ndc_label_name": "Bupivacaine in Dextrose Solution 0.75-8.25 % Intrathecal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69374099402", "ndc_label_name": "Bupivacaine in Dextrose Solution Prefilled Syringe 0.75-8.25 % (2 ML)", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409361311", "ndc_label_name": "Bupivacaine Spinal Solution 0.75-8.25 % Intrathecal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409361301", "ndc_label_name": "Bupivacaine Spinal SOLUTION 0.75-8.25 % Intrathecal", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054017613", "ndc_label_name": "Buprenorphine HCl TABLET SUBLINGUAL 2 MG SUBLINGUAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268012811", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121101930", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228315603", "ndc_label_name": "Buprenorphine HCl TABLET SUBLINGUAL 2 MG SUBLINGUAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72162134403", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700030230", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629712502", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518221700", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904715404", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629712501", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518222602", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858050103", "ndc_label_name": "Buprenorphine HCl TABLET SUBLINGUAL 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50383092493", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335095002", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335095001", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518222600", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687048111", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518222603", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335095003", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268012815", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687048121", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518222601", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189057960", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629947501", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756045983", "ndc_label_name": "Buprenorphine HCl TABLET SUBLINGUAL 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189058060", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189058090", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72888018230", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054017713", "ndc_label_name": "Buprenorphine HCl TABLET SUBLINGUAL 8 MG SUBLINGUAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687049211", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121203830", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090292400", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090157100", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42858050203", "ndc_label_name": "Buprenorphine HCl TABLET SUBLINGUAL 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335115403", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629712601", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00228315303", "ndc_label_name": "Buprenorphine HCl TABLET SUBLINGUAL 8 MG SUBLINGUAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335116302", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904715504", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268012911", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268012915", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518201401", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335116303", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687049221", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383093093", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162134503", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756046083", "ndc_label_name": "Buprenorphine HCl TABLET SUBLINGUAL 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335115402", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629712602", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72189058260", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518162500", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518221800", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518201400", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335116301", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335115401", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72888018330", "ndc_label_name": "Buprenorphine HCl Tablet Sublingual 8 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378876816", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781724964", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598058101", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378876893", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47781035803", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781724906", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742036530", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52427071211", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598058130", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52427071203", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47781035811", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742036501", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 12-3 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781721664", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378876516", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598057901", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52427069211", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781035503", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378876593", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598057930", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781721606", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781035511", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52427069203", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598058001", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 4-1 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781722706", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 4-1 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378876616", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 4-1 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378876693", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 4-1 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52427069403", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 4-1 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781035611", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 4-1 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598058030", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 4-1 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781722764", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 4-1 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781035603", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 4-1 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52427069411", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 4-1 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378876716", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781723864", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598058230", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598058201", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781723806", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47781035703", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378876793", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47781035711", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52427069811", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742036401", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52427069803", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742036430", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Film 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406192303", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054018813", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl TABLET SUBLINGUAL 2-0.5 MG SUBLINGUAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121101830", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268014415", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl TABLET SUBLINGUAL 2-0.5 MG SUBLINGUAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335129601", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228315403", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00406800503", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904700906", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858060103", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729054910", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429058630", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162041603", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl TABLET SUBLINGUAL 2-0.5 MG SUBLINGUAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62175045232", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268014411", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl TABLET SUBLINGUAL 2-0.5 MG SUBLINGUAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629948201", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756096983", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl TABLET SUBLINGUAL 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50383029493", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518100700", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700090130", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72162134603", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687062611", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687062665", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 2-0.5 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121203630", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42858060203", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904701006", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054018913", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl TABLET SUBLINGUAL 8-2 MG SUBLINGUAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729055010", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687063711", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406192403", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00228315503", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862060830", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268014511", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756097083", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl TABLET SUBLINGUAL 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383028793", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268014515", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62175045832", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00406802003", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl TABLET SUBLINGUAL 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429058730", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335172501", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518338900", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162041503", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl TABLET SUBLINGUAL 8-2 MG SUBLINGUAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629948301", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335185801", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335172502", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687063765", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162134703", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335137801", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518231100", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518312900", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335185802", "ndc_label_name": "Buprenorphine HCl-Naloxone HCl Tablet Sublingual 8-2 MG Sublingual", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42858049340", "ndc_label_name": "Buprenorphine Patch Weekly 10 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093365721", "ndc_label_name": "Buprenorphine Patch Weekly 10 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093360121", "ndc_label_name": "Buprenorphine PATCH WEEKLY 10 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093360140", "ndc_label_name": "Buprenorphine PATCH WEEKLY 10 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093365740", "ndc_label_name": "Buprenorphine Patch Weekly 10 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858058640", "ndc_label_name": "Buprenorphine Patch Weekly 15 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093360221", "ndc_label_name": "Buprenorphine PATCH WEEKLY 15 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093360240", "ndc_label_name": "Buprenorphine PATCH WEEKLY 15 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093365821", "ndc_label_name": "Buprenorphine Patch Weekly 15 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093365840", "ndc_label_name": "Buprenorphine Patch Weekly 15 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093360321", "ndc_label_name": "Buprenorphine PATCH WEEKLY 20 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093365940", "ndc_label_name": "Buprenorphine Patch Weekly 20 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093365921", "ndc_label_name": "Buprenorphine Patch Weekly 20 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093360340", "ndc_label_name": "Buprenorphine PATCH WEEKLY 20 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858083940", "ndc_label_name": "Buprenorphine Patch Weekly 20 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093360040", "ndc_label_name": "Buprenorphine PATCH WEEKLY 5 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093360021", "ndc_label_name": "Buprenorphine PATCH WEEKLY 5 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700056804", "ndc_label_name": "Buprenorphine Patch Weekly 5 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093365621", "ndc_label_name": "Buprenorphine Patch Weekly 5 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858075040", "ndc_label_name": "Buprenorphine Patch Weekly 5 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093365640", "ndc_label_name": "Buprenorphine Patch Weekly 5 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700057904", "ndc_label_name": "Buprenorphine Patch Weekly 5 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42858035340", "ndc_label_name": "Buprenorphine Patch Weekly 7.5 MCG/HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781516960", "ndc_label_name": "BuPROPion HCl ER (Smoking Det) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598086360", "ndc_label_name": "BuPROPion HCl ER (Smoking Det) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591354376", "ndc_label_name": "BuPROPion HCl ER (Smoking Det) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569616001", "ndc_label_name": "BuPROPion HCl ER (Smoking Det) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65084041442", "ndc_label_name": "BuPROPion HCl ER (Smoking Det) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090115000", "ndc_label_name": "BuPROPion HCl ER (Smoking Det) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378552101", "ndc_label_name": "BuPROPion HCl ER (Smoking Det) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591354360", "ndc_label_name": "BuPROPion HCl ER (Smoking Det) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569616000", "ndc_label_name": "BuPROPion HCl ER (Smoking Det) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090115001", "ndc_label_name": "BuPROPion HCl ER (Smoking Det) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722006601", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353053882", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185041001", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185041005", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591354005", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806041001", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722006605", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591354060", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806042401", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547028810", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185041060", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722006660", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547028809", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353073582", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353053816", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547028850", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353073518", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090674300", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904727061", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806041005", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335073688", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090713000", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335073686", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228017405", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598075105", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228017401", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806041060", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598075101", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002150903", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090734900", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090282000", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228017460", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090296400", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187095260", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806042460", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090258400", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429021605", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429021601", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187095214", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205038730", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002150900", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788717003", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598075160", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959080560", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919003660", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788717009", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788777606", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205038760", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187017660", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097087707", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335073613", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002150906", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788777603", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788781906", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189005730", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "77771017405", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187095230", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518305800", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429021660", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788717006", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788777609", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436005802", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084069701", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189005760", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629319603", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72789015860", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084069711", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "77771017460", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788781909", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788781903", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436005801", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518264100", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440720091", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440720081", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185041505", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185041560", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185041552", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806041505", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185041501", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353064060", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591354125", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722006705", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440720090", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440720060", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440720030", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806041560", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591354105", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547028910", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904658561", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806041501", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806042501", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440720085", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440720092", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547028950", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904721461", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335073713", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722006701", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063074430", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353054680", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090086100", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591354160", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090324902", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722006760", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090307800", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353054660", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353064030", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598075205", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090086201", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353054630", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090345300", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063091330", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090324900", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353064080", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335073786", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090086101", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090635301", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547028909", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090385400", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090385401", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090324903", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598075201", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090086200", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090086102", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187072630", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598075260", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090385402", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090687100", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090687101", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335073788", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090635300", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090086202", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029930", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090086103", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090385403", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090687103", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187005260", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090635302", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090635303", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090086203", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013501", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090324901", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090635400", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090742202", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629287303", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228017560", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090742201", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228017501", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013507", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090687102", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090742200", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090742203", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029980", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002134506", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959080660", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002134503", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788780702", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090687200", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228017505", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090742300", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788780709", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700089530", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919013630", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700064430", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934015190", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959080630", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760040798", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084070895", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934079130", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429021701", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187005278", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700089560", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335061201", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002134500", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919006360", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788780703", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610057060", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429021725", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187072690", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429021705", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029953", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629847301", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629287302", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788780706", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071012260", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919003830", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788780701", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429021760", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084070825", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544029960", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436005922", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205055030", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680802", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187005230", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934015696", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919013660", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788780708", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071012230", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934079160", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610057660", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436005901", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629287301", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205056560", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187072660", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436005902", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680801", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335000602", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610057680", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934015160", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205055060", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335000603", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680803", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013504", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680806", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335000607", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680808", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013506", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335000601", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610057080", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680809", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610057630", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518307900", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72162152905", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934015130", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189034960", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335000606", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205056530", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70518331800", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335000604", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335183703", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335000605", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934015196", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013503", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72189034930", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335170201", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934079190", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335170203", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013502", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013505", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335183701", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "77771017505", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "77771017560", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185111160", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722006860", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335073886", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591354260", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353018983", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598075360", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722006801", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806041160", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353090083", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806042660", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429021860", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788728309", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547029009", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788728301", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228017601", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335073888", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547029010", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187017860", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788779303", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788779309", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228017660", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788779306", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002153603", "ndc_label_name": "BuPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788717408", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788779301", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187056660", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "77771017660", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788728302", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788717409", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788779308", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788717401", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788728303", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788779302", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788717402", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788717403", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788728308", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788717406", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788728306", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436006001", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610058283", "ndc_label_name": "buPROPion HCl ER (SR) Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591333130", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781552810", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591333105", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115681110", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378200877", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261068002", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591333119", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00115681108", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261068007", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291018250", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10370010103", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "24979010107", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729044316", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261068090", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781552831", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729044310", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261068021", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436910301", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10370010150", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261068030", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806034809", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407020605", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261068020", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729044315", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090137202", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407020630", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "24979010106", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261068060", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806034830", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002149503", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356062730", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "24979010102", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079004701", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002149509", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261068014", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079004720", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598065505", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217027990", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291018230", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090290400", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569643202", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217027930", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261068028", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429035705", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090313900", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746075830", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291018290", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569643200", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629376202", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217027960", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598065530", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687031201", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268014011", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429035790", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806034805", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700068430", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629376205", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919067430", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268014013", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687031211", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002149500", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760069530", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063038790", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429035730", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180031906", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187076690", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407020690", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187012430", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217027914", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760069590", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598065590", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187012490", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693106", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629703301", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569643201", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071202306", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700025430", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919058930", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090137200", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629376203", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919006960", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001028704", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569910600", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382035316", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187071390", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919058960", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090137201", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629376206", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187072890", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377003412", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746075890", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693101", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629703302", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629376201", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429093330", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377003411", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001032205", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436001006", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429093305", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693108", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001032203", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629376204", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429093390", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377003413", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001032204", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335104401", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919067460", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436001002", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382035305", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001028703", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629703303", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205004590", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693103", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180031902", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629703305", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205007690", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097087505", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382035306", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180031909", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693109", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205029130", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097087502", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205004530", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097087512", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205029190", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436001004", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610034660", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10370010203", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781552910", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904657304", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598065605", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10370010200", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063038890", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261062707", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378200905", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10370010250", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781552931", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261062720", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45963014205", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "24979010206", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45963014290", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261062790", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729044410", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "24979010207", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "24979010202", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090105900", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090105901", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261062714", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268014111", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806034909", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729044416", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261062760", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261062730", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090272100", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079010901", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261062721", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700014330", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700014390", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261062702", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358036530", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806034905", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268014115", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002150803", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291018330", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700014360", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788734708", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261062728", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090272101", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407020730", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079010903", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180032009", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291018350", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700025730", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097087602", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569596901", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407020705", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407020790", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180032002", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382035405", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598065630", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700082030", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377003511", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629331601", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700014630", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629331603", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788722103", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788712106", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "45963014230", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187081930", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377003512", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001032105", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700025790", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001032104", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335068701", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788712109", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569596900", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629331602", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071131100", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084025221", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429035805", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788734706", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382035406", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788734703", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429035830", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629331605", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788712103", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335082401", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429035890", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788734709", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788722108", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436001102", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629331604", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084025211", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788734701", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610013130", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001032103", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70377003513", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680903", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180032006", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680906", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436001106", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680909", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680901", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788722101", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335082403", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788722106", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788680908", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335033101", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788712101", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335082405", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788712108", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282048130", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788722109", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097087612", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436001104", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610013160", "ndc_label_name": "buPROPion HCl ER (XL) Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781063730", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 450 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64679083001", "ndc_label_name": "BuPROPion HCl ER (XL) Tablet Extended Release 24 Hour 450 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378043505", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904663661", "ndc_label_name": "BuPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001307", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353076780", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720430", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781106401", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781106410", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378043501", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720460", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001328", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353076783", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999034990", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001321", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001314", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001390", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155019201", "ndc_label_name": "BuPROPion HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063099430", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001340", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353076792", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090186900", "ndc_label_name": "BuPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001330", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057553", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057570", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001360", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268014311", "ndc_label_name": "BuPROPion HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057580", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090078503", "ndc_label_name": "BuPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090186903", "ndc_label_name": "BuPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358036260", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353076753", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999034960", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057560", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959065502", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057583", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569539103", "ndc_label_name": "BuPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436910102", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353076770", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429094701", "ndc_label_name": "BuPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959065500", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353076760", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864080890", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057592", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629323305", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959065560", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079094401", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061601", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959065540", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268014315", "ndc_label_name": "BuPROPion HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505015701", "ndc_label_name": "BuPROPion HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090078500", "ndc_label_name": "BuPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061640", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959065590", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079094420", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061610", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429074701", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959065530", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687035111", "ndc_label_name": "BuPROPion HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569539102", "ndc_label_name": "BuPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267061460", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002141700", "ndc_label_name": "BuPROPion HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002141706", "ndc_label_name": "BuPROPion HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061625", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687035101", "ndc_label_name": "BuPROPion HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002141703", "ndc_label_name": "BuPROPion HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061630", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760081790", "ndc_label_name": "BuPROPion HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544089760", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289073330", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569539100", "ndc_label_name": "BuPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061670", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061674", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289073360", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061672", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629323302", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980020201", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700077960", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864080830", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335018202", "ndc_label_name": "BuPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544089780", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061604", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061677", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061620", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544089783", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629323301", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629323303", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061680", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788731903", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061612", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544089753", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788731901", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788731906", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629323304", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629323306", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610016483", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788731909", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061615", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061650", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061628", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267061430", "ndc_label_name": "BuPROPion HCl TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061660", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001019800", "ndc_label_name": "BuPROPion HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874061690", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001030900", "ndc_label_name": "BuPROPion HCl TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097091807", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788731908", "ndc_label_name": "buPROPion HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268014215", "ndc_label_name": "BuPROPion HCl TABLET 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356073530", "ndc_label_name": "BuPROPion HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378043305", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720330", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904663561", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378043301", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063028460", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155019101", "ndc_label_name": "BuPROPion HCl TABLET 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959089860", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002144703", "ndc_label_name": "BuPROPion HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063088060", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781105310", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057480", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720360", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063028498", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063088030", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505015801", "ndc_label_name": "BuPROPion HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629344901", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057453", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079094356", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544040680", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781105301", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057488", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919003760", "ndc_label_name": "BuPROPion HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739070610", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544040653", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057494", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335001302", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001030800", "ndc_label_name": "BuPROPion HCl TABLET 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063028430", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243035106", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629344902", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544040651", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544089251", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999091830", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610037270", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788699406", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353057470", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788699409", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980020101", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544089294", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544089280", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079094301", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544040694", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788699408", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999091860", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335079101", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544089270", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788699401", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610037253", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079094330", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268014211", "ndc_label_name": "BuPROPion HCl TABLET 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335001301", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610037280", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002144706", "ndc_label_name": "BuPROPion HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079094320", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097091707", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610038494", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864079430", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002144700", "ndc_label_name": "BuPROPion HCl TABLET 75 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610038480", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687034001", "ndc_label_name": "BuPROPion HCl TABLET 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429074601", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687034011", "ndc_label_name": "BuPROPion HCl TABLET 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610037294", "ndc_label_name": "buPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544040670", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544089253", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001019900", "ndc_label_name": "BuPROPion HCl TABLET 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788699403", "ndc_label_name": "BuPROPion HCl Tablet 75 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093005401", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300024505", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115169103", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093005405", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544017630", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155002401", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720790", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591065810", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115169102", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806008405", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24689090701", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115169101", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155002405", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24689090705", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591065805", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063018690", "ndc_label_name": "BusPIRone HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378115005", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353061053", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353061092", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378115001", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300024501", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001430", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729020201", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063078590", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720760", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999081260", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999081200", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720730", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806008401", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358005510", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001460", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353006070", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729020216", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407020205", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090211000", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591065801", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063018660", "ndc_label_name": "BusPIRone HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063018645", "ndc_label_name": "BusPIRone HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353006053", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090326000", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999081230", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959067660", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090211003", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544017690", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353006080", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353006060", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353006092", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090326003", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090211005", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919060030", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569525300", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001490", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090277300", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090326001", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353061060", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090326005", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053090", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073760", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569525303", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358005560", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090326004", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569525305", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353061080", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569525301", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700083730", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610020860", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053030", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353061070", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079098601", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429029205", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079098656", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864078230", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700083790", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610028180", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58517034030", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090211001", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079098620", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919060060", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407020201", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187090490", "ndc_label_name": "BusPIRone HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629304701", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919060090", "ndc_label_name": "BusPIRone HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429029201", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090211004", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700052690", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380074206", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569901100", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874057128", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629304702", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788701703", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629304704", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959067690", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874057160", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788892903", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700052630", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874057130", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874057101", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788892906", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874057120", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569525304", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380074207", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610030270", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053060", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874057190", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073753", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629304703", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243035909", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380074208", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073792", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874057110", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187090430", "ndc_label_name": "BusPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267052845", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073770", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267052860", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267052890", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382018105", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382018101", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788701701", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874057115", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610020880", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544073780", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610025780", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788701706", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610030253", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335000702", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65243024409", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788892909", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788892901", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610020853", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267052820", "ndc_label_name": "BusPIRone HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610030260", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238111701", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610030280", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788701709", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610030292", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610025753", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238111705", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610025760", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335000701", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610028160", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610028153", "ndc_label_name": "busPIRone HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720860", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378116591", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378116505", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115169219", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300024605", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093100305", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093100301", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591071818", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729020301", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720830", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591071860", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155002501", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300024616", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115169202", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115169213", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155002505", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729020312", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24689092106", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155002506", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569550701", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001560", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378116580", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720890", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24689092101", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300024601", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001500", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155002508", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700010060", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358005630", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904689961", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591071805", "ndc_label_name": "BusPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001530", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001590", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959071360", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24689092105", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687030821", "ndc_label_name": "BusPIRone HCl TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407020305", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806008501", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300024618", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353060730", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090211101", "ndc_label_name": "BusPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919057930", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353060760", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760054860", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569550702", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090211103", "ndc_label_name": "BusPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806008505", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436091902", "ndc_label_name": "BusPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407020360", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629174704", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353060780", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874095410", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700052990", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079096020", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959071300", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700052960", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569550703", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874095415", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079096001", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335027204", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874095401", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079096056", "ndc_label_name": "BusPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959071390", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429029360", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874095430", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874095460", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959071345", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610020630", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382018205", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959071330", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700043360", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629174701", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788976603", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380074318", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864096315", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629174702", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788746206", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700080360", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187040290", "ndc_label_name": "BusPIRone HCl TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788976601", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610029980", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238111805", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687030811", "ndc_label_name": "BusPIRone HCl TABLET 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238111806", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788746209", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429029305", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874095420", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335027205", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610034453", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205028090", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629174703", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610029930", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380074303", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238111801", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267087530", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610029953", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382018201", "ndc_label_name": "BusPIRone HCl TABLET 15 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610029960", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205028030", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335027201", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788976606", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335027206", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610018353", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610029160", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788976609", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610020660", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335027202", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335027203", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335098503", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610018360", "ndc_label_name": "busPIRone HCl Tablet 15 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093520006", "ndc_label_name": "BusPIRone HCl TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093520005", "ndc_label_name": "BusPIRone HCl TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291017750", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806008660", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155009706", "ndc_label_name": "BusPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24689093306", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378117591", "ndc_label_name": "BusPIRone HCl TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079099420", "ndc_label_name": "BusPIRone HCl TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729028912", "ndc_label_name": "BusPIRone HCl TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358005730", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629333301", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629333302", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079099401", "ndc_label_name": "BusPIRone HCl TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874088730", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155009705", "ndc_label_name": "BusPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382018314", "ndc_label_name": "BusPIRone HCl TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959083460", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358005760", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335055202", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335099106", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335099103", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874088760", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300024705", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806008605", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300024716", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380074403", "ndc_label_name": "BusPIRone HCl TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382018305", "ndc_label_name": "BusPIRone HCl TABLET 30 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335099101", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238111906", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335099102", "ndc_label_name": "busPIRone HCl Tablet 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155002305", "ndc_label_name": "BusPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115169003", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115169001", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720690", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093005305", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591065705", "ndc_label_name": "BusPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591065701", "ndc_label_name": "BusPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093005301", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24689078101", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806008201", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115169002", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591065710", "ndc_label_name": "BusPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378114005", "ndc_label_name": "BusPIRone HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729020001", "ndc_label_name": "BusPIRone HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729020016", "ndc_label_name": "BusPIRone HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720660", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358005490", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353060980", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378114001", "ndc_label_name": "BusPIRone HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300024401", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440720630", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569913000", "ndc_label_name": "BusPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155002301", "ndc_label_name": "BusPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358005430", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079098520", "ndc_label_name": "BusPIRone HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407020105", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29300024405", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380074106", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353060960", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919016630", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24689078105", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217027660", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700000130", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217027630", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806008205", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788698401", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429029105", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919016660", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353060953", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429029101", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380074107", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874068820", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407020101", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610020353", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629319701", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629319702", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079098501", "ndc_label_name": "BusPIRone HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629319704", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788687801", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874068830", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959065430", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610030760", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874068801", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629319703", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544068660", "ndc_label_name": "BusPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874068810", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610020380", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380074108", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919016690", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874068890", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874068828", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544068653", "ndc_label_name": "BusPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382018001", "ndc_label_name": "BusPIRone HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382018005", "ndc_label_name": "BusPIRone HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544068680", "ndc_label_name": "BusPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788687806", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919096590", "ndc_label_name": "BusPIRone HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238111501", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788698403", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610026660", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788698409", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610020360", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788698406", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788687809", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874068860", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610026760", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610026680", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238111505", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610016560", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610026780", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610026753", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610026653", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788687803", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610016553", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610016580", "ndc_label_name": "busPIRone HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378114501", "ndc_label_name": "BusPIRone HCl TABLET 7.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700035430", "ndc_label_name": "BusPIRone HCl TABLET 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729020101", "ndc_label_name": "BusPIRone HCl TABLET 7.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806008301", "ndc_label_name": "BusPIRone HCl Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24689078501", "ndc_label_name": "busPIRone HCl Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380078706", "ndc_label_name": "BusPIRone HCl TABLET 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238111601", "ndc_label_name": "busPIRone HCl Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610034260", "ndc_label_name": "busPIRone HCl Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42806008305", "ndc_label_name": "BusPIRone HCl Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884072501", "ndc_label_name": "busPIRone HCl Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291017690", "ndc_label_name": "busPIRone HCl Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884072505", "ndc_label_name": "busPIRone HCl Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610036060", "ndc_label_name": "busPIRone HCl Tablet 7.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505617700", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45963064057", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860021610", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409111201", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517092008", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729035103", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45963064077", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457089308", "ndc_label_name": "Busulfan SOLUTION 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021024110", "ndc_label_name": "Busulfan SOLUTION 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457089300", "ndc_label_name": "Busulfan SOLUTION 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485021001", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409111210", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729035192", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70121124407", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517092001", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505617708", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485021008", "ndc_label_name": "Busulfan Solution 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148007090", "ndc_label_name": "Busulfex SOLUTION 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59148007091", "ndc_label_name": "Busulfex SOLUTION 6 MG/ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862054401", "ndc_label_name": "Butalbital-Acetaminophen Capsule 50-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69499034230", "ndc_label_name": "Butalbital-Acetaminophen Capsule 50-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70010005401", "ndc_label_name": "Butalbital-Acetaminophen Capsule 50-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781064401", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862053801", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68682030601", "ndc_label_name": "Butalbital-Acetaminophen TABLET 50-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781053401", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781062801", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781053501", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358005830", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603254021", "ndc_label_name": "Butalbital-Acetaminophen TABLET 50-325 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69499030240", "ndc_label_name": "Butalbital-Acetaminophen TABLET 50-325 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70362072101", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68047072101", "ndc_label_name": "Butalbital-Acetaminophen TABLET 50-325 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68047072130", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071042130", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071042160", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071042190", "ndc_label_name": "Butalbital-Acetaminophen Tablet 50-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591264101", "ndc_label_name": "Butalbital-APAP-Caff-Cod CAPSULE 50-300-40-30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440721130", "ndc_label_name": "Butalbital-APAP-Caff-Cod Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591322001", "ndc_label_name": "Butalbital-APAP-Caff-Cod CAPSULE 50-325-40-30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603255321", "ndc_label_name": "Butalbital-APAP-Caff-Cod Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629315201", "ndc_label_name": "Butalbital-APAP-Caff-Cod Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006130", "ndc_label_name": "Butalbital-APAP-Caff-Cod Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959091260", "ndc_label_name": "Butalbital-APAP-Caff-Cod Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006190", "ndc_label_name": "Butalbital-APAP-Caff-Cod Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51991007301", "ndc_label_name": "Butalbital-APAP-Caff-Cod CAPSULE 50-325-40-30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629315202", "ndc_label_name": "Butalbital-APAP-Caff-Cod Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407020001", "ndc_label_name": "Butalbital-APAP-Caffeine Capsule 50-300-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291018101", "ndc_label_name": "Butalbital-APAP-Caffeine Capsule 50-300-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591264001", "ndc_label_name": "Butalbital-APAP-Caffeine CAPSULE 50-300-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527409537", "ndc_label_name": "Butalbital-APAP-Caffeine Capsule 50-300-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42195095510", "ndc_label_name": "Butalbital-APAP-Caffeine CAPSULE 50-300-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135062801", "ndc_label_name": "Butalbital-APAP-Caffeine CAPSULE 50-300-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591264005", "ndc_label_name": "Butalbital-APAP-Caffeine CAPSULE 50-300-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11534018704", "ndc_label_name": "Butalbital-APAP-Caffeine CAPSULE 50-300-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11534018701", "ndc_label_name": "Butalbital-APAP-Caffeine CAPSULE 50-300-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527409437", "ndc_label_name": "Butalbital-APAP-Caffeine Capsule 50-325-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13107007501", "ndc_label_name": "Butalbital-APAP-Caffeine Capsule 50-325-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862017901", "ndc_label_name": "Butalbital-APAP-Caffeine CAPSULE 50-325-40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904693806", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000800", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527169505", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527169501", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143178705", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904653860", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143178701", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090210500", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000840", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000803", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603254428", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591336901", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591336905", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10702025301", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603254421", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090210503", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358005930", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000810", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904653806", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904653840", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603254402", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000884", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000802", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268013911", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036960", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358005960", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904653880", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000890", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603254432", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358005920", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000814", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217012528", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353027530", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353027560", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000820", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036920", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10702025350", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036910", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000821", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289087960", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353027570", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090256400", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000830", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781053605", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000828", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036915", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999015130", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864085730", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999015120", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090256403", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000860", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436169501", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261000856", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353023660", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187093314", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919002230", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999015160", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217012584", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063036930", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217012540", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781053601", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353023670", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629177401", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919002290", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268013913", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569253805", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353023630", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569253800", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436485601", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353027553", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874044802", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874044801", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874044803", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289087920", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353023653", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569253803", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436485602", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781062505", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874044810", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874044820", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66116064830", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700066230", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781062501", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289087910", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862054005", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289087915", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874044830", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874044850", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544038370", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429058901", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862054001", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700066260", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217012502", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289087930", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544038330", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874044890", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544039470", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629177405", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217012530", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429058905", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217012556", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919002260", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544039453", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267003930", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693906", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629177408", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217012590", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629177404", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217012560", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187093330", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693901", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267003960", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874044860", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267003912", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629177403", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629177407", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693908", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629177402", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69367020305", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544039430", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036502", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267003990", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629177406", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084039665", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036503", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084039611", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036504", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693903", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036508", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544039460", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544038353", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036500", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036509", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693909", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036505", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036501", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544038360", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788693902", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610004260", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036506", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610004270", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69367020301", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036507", "ndc_label_name": "Butalbital-APAP-Caffeine TABLET 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610004253", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610004230", "ndc_label_name": "Butalbital-APAP-Caffeine Tablet 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591354605", "ndc_label_name": "Butalbital-ASA-Caff-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086500", "ndc_label_name": "Butalbital-ASA-Caff-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591354601", "ndc_label_name": "Butalbital-ASA-Caff-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959086530", "ndc_label_name": "Butalbital-ASA-Caff-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874021920", "ndc_label_name": "Butalbital-ASA-Caff-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527131201", "ndc_label_name": "Butalbital-ASA-Caff-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874021925", "ndc_label_name": "Butalbital-ASA-Caff-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874021901", "ndc_label_name": "Butalbital-ASA-Caff-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874021930", "ndc_label_name": "Butalbital-ASA-Caff-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69238199301", "ndc_label_name": "Butalbital-ASA-Caff-Codeine Capsule 50-325-40-30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00527155201", "ndc_label_name": "Butalbital-Aspirin-Caffeine CAPSULE 50-325-40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591321901", "ndc_label_name": "Butalbital-Aspirin-Caffeine Capsule 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090158000", "ndc_label_name": "Butalbital-Aspirin-Caffeine Capsule 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090146500", "ndc_label_name": "Butalbital-Aspirin-Caffeine Capsule 50-325-40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11917017821", "ndc_label_name": "Butenafine HCl Cream 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51672210008", "ndc_label_name": "Butenafine HCl CREAM 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51672210002", "ndc_label_name": "Butenafine HCl CREAM 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00054309036", "ndc_label_name": "Butorphanol Tartrate SOLUTION 10 MG/ML NASAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505081301", "ndc_label_name": "Butorphanol Tartrate SOLUTION 10 MG/ML NASAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378963943", "ndc_label_name": "Butorphanol Tartrate Solution 10 MG/ML Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569598800", "ndc_label_name": "Butorphanol Tartrate Solution 10 MG/ML Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356060504", "ndc_label_name": "Butrans PATCH WEEKLY 10 MCG/HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569632500", "ndc_label_name": "Butrans Patch Weekly 10 MCG/HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59011075104", "ndc_label_name": "Butrans Patch Weekly 10 MCG/HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59011075804", "ndc_label_name": "Butrans Patch Weekly 15 MCG/HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356060604", "ndc_label_name": "Butrans Patch Weekly 20 MCG/HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569632600", "ndc_label_name": "Butrans Patch Weekly 20 MCG/HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59011075204", "ndc_label_name": "Butrans Patch Weekly 20 MCG/HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356060704", "ndc_label_name": "Butrans Patch Weekly 5 MCG/HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59011075004", "ndc_label_name": "Butrans Patch Weekly 5 MCG/HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59011075704", "ndc_label_name": "Butrans Patch Weekly 7.5 MCG/HR Transdermal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310654001", "ndc_label_name": "Bydureon BCise Auto-injector 2 MG/0.85ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310654004", "ndc_label_name": "Bydureon BCise Auto-injector 2 MG/0.85ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310652401", "ndc_label_name": "Byetta 10 MCG Pen Solution Pen-injector 10 MCG/0.04ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310651201", "ndc_label_name": "Byetta 5 MCG Pen Solution Pen-injector 5 MCG/0.02ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71390001111", "ndc_label_name": "Byfavo Solution Reconstituted 20 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71390001100", "ndc_label_name": "Byfavo Solution Reconstituted 20 MG Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "74528002001", "ndc_label_name": "Bylvay (Pellets) Capsule Sprinkle 200 MCG Oral", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "74528006001", "ndc_label_name": "Bylvay (Pellets) Capsule Sprinkle 600 MCG Oral", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "74528012001", "ndc_label_name": "Bylvay Capsule 1200 MCG Oral", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "74528004001", "ndc_label_name": "Bylvay Capsule 400 MCG Oral", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64406001901", "ndc_label_name": "Byooviz Solution 0.5 MG/0.05ML Intravitreal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64406001907", "ndc_label_name": "Byooviz Solution 0.5 MG/0.05ML Intravitreal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456141030", "ndc_label_name": "Bystolic Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456141090", "ndc_label_name": "Bystolic Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569634200", "ndc_label_name": "Bystolic Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569634201", "ndc_label_name": "Bystolic Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090130700", "ndc_label_name": "Bystolic Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456140211", "ndc_label_name": "Bystolic Tablet 2.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456140230", "ndc_label_name": "Bystolic Tablet 2.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456140263", "ndc_label_name": "Bystolic Tablet 2.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090332600", "ndc_label_name": "Bystolic Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456142030", "ndc_label_name": "Bystolic Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569677000", "ndc_label_name": "Bystolic Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456142090", "ndc_label_name": "Bystolic Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569611900", "ndc_label_name": "Bystolic Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456140563", "ndc_label_name": "Bystolic Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456140511", "ndc_label_name": "Bystolic Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456140590", "ndc_label_name": "Bystolic Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456140530", "ndc_label_name": "Bystolic Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090112700", "ndc_label_name": "Bystolic Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11845011739", "ndc_label_name": "C 1000 TABLET 1000 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40986001770", "ndc_label_name": "C 1000 TABLET 1000 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845011735", "ndc_label_name": "C 1000 TABLET 1000 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845011709", "ndc_label_name": "C 250 TABLET 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205042478", "ndc_label_name": "C 250 Tablet 250 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40986002074", "ndc_label_name": "C 250 TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58526000537", "ndc_label_name": "C 500 TABLET CHEWABLE 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205042578", "ndc_label_name": "C 500/Rose Hips Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985022433", "ndc_label_name": "C-1000 TABLET 1000 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205042378", "ndc_label_name": "C-1000/Rose Hips Tablet 1000 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985022383", "ndc_label_name": "C-1000/Rose Hips TABLET 1000 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985022294", "ndc_label_name": "C-250 TABLET 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292022321", "ndc_label_name": "C-250 TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10006070047", "ndc_label_name": "C-250 Tablet Chewable 250 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292022320", "ndc_label_name": "C-250 TABLET CHEWABLE 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292022322", "ndc_label_name": "C-500 TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10006070040", "ndc_label_name": "C-500 Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10006073049", "ndc_label_name": "C-500 Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50268086115", "ndc_label_name": "C-500 TABLET CHEWABLE 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985021024", "ndc_label_name": "C-500 TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845062901", "ndc_label_name": "C-500 TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536329101", "ndc_label_name": "C-500 Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50268086111", "ndc_label_name": "C-500 TABLET CHEWABLE 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292022323", "ndc_label_name": "C-500 TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "81131074913", "ndc_label_name": "C-Chewable TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "23359010530", "ndc_label_name": "C-Nate DHA CAPSULE 28-1-200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49702025315", "ndc_label_name": "Cabenuva Suspension Extended Release 400 & 600 MG/2ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49702024015", "ndc_label_name": "Cabenuva Suspension Extended Release 600 & 900 MG/3ML Intramuscular", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762100501", "ndc_label_name": "Cabergoline TABLET 0.5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884067314", "ndc_label_name": "Cabergoline Tablet 0.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505259702", "ndc_label_name": "Cabergoline Tablet 0.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093542088", "ndc_label_name": "Cabergoline TABLET 0.5 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742011808", "ndc_label_name": "Cabergoline Tablet 0.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58468022501", "ndc_label_name": "Cablivi Kit 11 MG Injection", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42388002426", "ndc_label_name": "Cabometyx Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42388002526", "ndc_label_name": "Cabometyx Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42388002326", "ndc_label_name": "Cabometyx Tablet 60 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187000625", "ndc_label_name": "Cabtreo Gel 0.15-3.1-1.2 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00069216030", "ndc_label_name": "Caduet Tablet 10-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569588100", "ndc_label_name": "Caduet Tablet 10-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569595100", "ndc_label_name": "Caduet Tablet 10-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069218030", "ndc_label_name": "Caduet Tablet 10-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069225030", "ndc_label_name": "Caduet Tablet 10-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569609900", "ndc_label_name": "Caduet Tablet 10-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069227030", "ndc_label_name": "Caduet Tablet 10-80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999098930", "ndc_label_name": "Caduet TABLET 5-10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069215030", "ndc_label_name": "Caduet Tablet 5-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569570400", "ndc_label_name": "Caduet Tablet 5-10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069217030", "ndc_label_name": "Caduet Tablet 5-20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069219030", "ndc_label_name": "Caduet Tablet 5-40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069226030", "ndc_label_name": "Caduet Tablet 5-80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00641616410", "ndc_label_name": "Cafcit Solution 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641616401", "ndc_label_name": "Cafcit Solution 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289096012", "ndc_label_name": "Cafergot Tablet 1-100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781540501", "ndc_label_name": "Cafergot Tablet 1-100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874107203", "ndc_label_name": "Cafergot Tablet 1-100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323040603", "ndc_label_name": "Caffeine Citrate SOLUTION 20 MG/ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335028927", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641626710", "ndc_label_name": "Caffeine Citrate Solution 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42571024469", "ndc_label_name": "Caffeine Citrate Solution 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641626701", "ndc_label_name": "Caffeine Citrate Solution 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00517002010", "ndc_label_name": "Caffeine Citrate Solution 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021060103", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335028926", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51754050001", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335028940", "ndc_label_name": "Caffeine Citrate Solution 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323040703", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150018703", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323040704", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485010401", "ndc_label_name": "Caffeine Citrate Solution 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51754050201", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485010410", "ndc_label_name": "Caffeine Citrate Solution 60 MG/3ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51754050103", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335029027", "ndc_label_name": "Caffeine Citrate Solution 60 MG/3ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021060203", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51754050303", "ndc_label_name": "Caffeine Citrate SOLUTION 60 MG/3ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00536100715", "ndc_label_name": "Cal-Gest Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536474297", "ndc_label_name": "Cal-Gest Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00025190131", "ndc_label_name": "Calan SR Tablet Extended Release 120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025191131", "ndc_label_name": "Calan SR Tablet Extended Release 180 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025189151", "ndc_label_name": "Calan SR Tablet Extended Release 240 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025189131", "ndc_label_name": "Calan SR Tablet Extended Release 240 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118997606", "ndc_label_name": "Calcipotriene CREAM 0.005 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993087778", "ndc_label_name": "Calcipotriene CREAM 0.005 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781711735", "ndc_label_name": "Calcipotriene Cream 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462050165", "ndc_label_name": "Calcipotriene CREAM 0.005 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993087761", "ndc_label_name": "Calcipotriene CREAM 0.005 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714076302", "ndc_label_name": "Calcipotriene Cream 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781711783", "ndc_label_name": "Calcipotriene Cream 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714076301", "ndc_label_name": "Calcipotriene Cream 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462050166", "ndc_label_name": "Calcipotriene CREAM 0.005 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "73308035760", "ndc_label_name": "Calcipotriene Foam 0.005 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993087878", "ndc_label_name": "Calcipotriene Ointment 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462031065", "ndc_label_name": "Calcipotriene Ointment 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672415404", "ndc_label_name": "Calcipotriene OINTMENT 0.005 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462031066", "ndc_label_name": "Calcipotriene Ointment 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993087861", "ndc_label_name": "Calcipotriene Ointment 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672415403", "ndc_label_name": "Calcipotriene OINTMENT 0.005 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713031853", "ndc_label_name": "Calcipotriene Solution 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00115147555", "ndc_label_name": "Calcipotriene Solution 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168040060", "ndc_label_name": "Calcipotriene Solution 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383073202", "ndc_label_name": "Calcipotriene Solution 0.005 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993093861", "ndc_label_name": "Calcipotriene-Betameth Diprop Ointment 0.005-0.064 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802081601", "ndc_label_name": "Calcipotriene-Betameth Diprop Ointment 0.005-0.064 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781716595", "ndc_label_name": "Calcipotriene-Betameth Diprop Ointment 0.005-0.064 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781716535", "ndc_label_name": "Calcipotriene-Betameth Diprop Ointment 0.005-0.064 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802081696", "ndc_label_name": "Calcipotriene-Betameth Diprop Ointment 0.005-0.064 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802098901", "ndc_label_name": "Calcipotriene-Betameth Diprop Ointment 0.005-0.064 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802098996", "ndc_label_name": "Calcipotriene-Betameth Diprop Ointment 0.005-0.064 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993093865", "ndc_label_name": "Calcipotriene-Betameth Diprop Ointment 0.005-0.064 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993093761", "ndc_label_name": "Calcipotriene-Betameth Diprop Suspension 0.005-0.064 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993093778", "ndc_label_name": "Calcipotriene-Betameth Diprop Suspension 0.005-0.064 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884016111", "ndc_label_name": "Calcitonin (Salmon) SOLUTION 200 UNIT/ACT NASAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781632079", "ndc_label_name": "Calcitonin (Salmon) Solution 200 UNIT/ACT Nasal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505082306", "ndc_label_name": "Calcitonin (Salmon) SOLUTION 200 UNIT/ACT NASAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42023020501", "ndc_label_name": "Calcitonin (Salmon) Solution 200 UNIT/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "24201040002", "ndc_label_name": "Calcitonin (Salmon) Solution 200 UNIT/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43598005111", "ndc_label_name": "Calcitonin (Salmon) Solution 200 UNIT/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63323086502", "ndc_label_name": "Calcitonin (Salmon) Solution 200 UNIT/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097077032", "ndc_label_name": "Calcitonin (Salmon) Solution 200 UNIT/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904527260", "ndc_label_name": "Calcitrate Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "17856527202", "ndc_label_name": "Calcitrate Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51672527804", "ndc_label_name": "Calcitrene Ointment 0.005 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672527803", "ndc_label_name": "Calcitrene OINTMENT 0.005 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054000725", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155066203", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440721599", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054000713", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093065701", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687034511", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407016930", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155066201", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155011801", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407016901", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155011803", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093735201", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353003430", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68258906101", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67544103581", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23629000910", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353003409", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452020720", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353013809", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353063309", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353003481", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353063381", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868458400", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629732302", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353013830", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429013301", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66336085190", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380072306", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353099809", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084047501", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084047511", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43353063330", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304023901", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429013330", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452020713", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687034501", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304023930", "ndc_label_name": "Calcitriol CAPSULE 0.25 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629732301", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380072304", "ndc_label_name": "Calcitriol Capsule 0.25 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155066301", "ndc_label_name": "Calcitriol Capsule 0.5 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304024001", "ndc_label_name": "Calcitriol CAPSULE 0.5 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093735301", "ndc_label_name": "Calcitriol CAPSULE 0.5 MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69452020820", "ndc_label_name": "Calcitriol Capsule 0.5 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155011901", "ndc_label_name": "Calcitriol Capsule 0.5 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380072406", "ndc_label_name": "Calcitriol Capsule 0.5 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407017001", "ndc_label_name": "Calcitriol Capsule 0.5 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429013401", "ndc_label_name": "Calcitriol CAPSULE 0.5 MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802060801", "ndc_label_name": "Calcitriol OINTMENT 3 MCG/GM EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72266025101", "ndc_label_name": "Calcitriol Solution 1 MCG/ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478093101", "ndc_label_name": "Calcitriol Solution 1 MCG/ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72266025110", "ndc_label_name": "Calcitriol Solution 1 MCG/ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054312041", "ndc_label_name": "Calcitriol SOLUTION 1 MCG/ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980044715", "ndc_label_name": "Calcitriol Solution 1 MCG/ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304024159", "ndc_label_name": "Calcitriol SOLUTION 1 MCG/ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "80681013900", "ndc_label_name": "Calcium + Vitamin D3 Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985027519", "ndc_label_name": "Calcium 500 + D3 Tablet 500-15 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985027522", "ndc_label_name": "Calcium 500 + D3 Tablet 500-15 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007546", "ndc_label_name": "Calcium 500+D Tablet 500-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917016636", "ndc_label_name": "Calcium 500+D Tablet 500-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917014685", "ndc_label_name": "Calcium 500+D Tablet 500-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917017124", "ndc_label_name": "Calcium 500+D3 Tablet 500-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917017122", "ndc_label_name": "Calcium 500+D3 Tablet 500-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292055694", "ndc_label_name": "Calcium 600 TABLET 1500 (600 Ca) MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "21695099930", "ndc_label_name": "Calcium 600 TABLET 1500 (600 Ca) MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985027533", "ndc_label_name": "Calcium 600 Tablet 1500 (600 Ca) MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896074806", "ndc_label_name": "Calcium 600+D Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292056392", "ndc_label_name": "Calcium 600/Vitamin D Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292055643", "ndc_label_name": "Calcium 600/Vitamin D Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35046000057", "ndc_label_name": "Calcium 600/Vitamin D3 Tablet 600-20 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35046000063", "ndc_label_name": "Calcium 600/Vitamin D3 Tablet 600-20 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "62135019122", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162059020", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097086283", "ndc_label_name": "Calcium Acetate (Phos Binder) CAPSULE 667 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781208102", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054008826", "ndc_label_name": "Calcium Acetate (Phos Binder) CAPSULE 667 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904666825", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054008813", "ndc_label_name": "Calcium Acetate (Phos Binder) CAPSULE 667 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135062902", "ndc_label_name": "Calcium Acetate (Phos Binder) CAPSULE 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084047901", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268014811", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904654606", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155053102", "ndc_label_name": "Calcium Acetate (Phos Binder) CAPSULE 667 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291018920", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429049102", "ndc_label_name": "Calcium Acetate (Phos Binder) CAPSULE 667 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904654661", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "17856008802", "ndc_label_name": "Calcium Acetate (Phos Binder) CAPSULE 667 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084047911", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282037702", "ndc_label_name": "Calcium Acetate (Phos Binder) CAPSULE 667 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268014815", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49230064441", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68094000261", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29033002602", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51293082502", "ndc_label_name": "Calcium Acetate (Phos Binder) CAPSULE 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180013415", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68094000259", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55154496100", "ndc_label_name": "Calcium Acetate (Phos Binder) Capsule 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00574011302", "ndc_label_name": "Calcium Acetate (Phos Binder) Tablet 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155062102", "ndc_label_name": "Calcium Acetate (Phos Binder) TABLET 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71321080320", "ndc_label_name": "Calcium Acetate (Phos Binder) Tablet 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "62135019222", "ndc_label_name": "Calcium Acetate Tablet 667 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "36800046880", "ndc_label_name": "Calcium Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800048980", "ndc_label_name": "Calcium Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113017980", "ndc_label_name": "Calcium Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536122922", "ndc_label_name": "Calcium Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536104922", "ndc_label_name": "Calcium Antacid Extra Strength Tablet Chewable 750 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090323000", "ndc_label_name": "Calcium Antacid Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00113047847", "ndc_label_name": "Calcium Antacid Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "48433010601", "ndc_label_name": "Calcium Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904641292", "ndc_label_name": "Calcium Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63868005315", "ndc_label_name": "Calcium Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864000150", "ndc_label_name": "Calcium Antacid Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70518041500", "ndc_label_name": "Calcium Antacid Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "31604001886", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 500-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845007555", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 500-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "31604002517", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 500-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00440722792", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904323306", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904323393", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "77333011525", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904323392", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68752064098", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "33261079103", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904323352", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629007200", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "77333011510", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629001681", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "17856323302", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68752064060", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68752064093", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-10 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "20555001700", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-400 MG-UNIT Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904585652", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904585692", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "48107004925", "ndc_label_name": "Calcium Carb-Cholecalciferol Tablet 600-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "17856311730", "ndc_label_name": "Calcium Carbonate Antacid Suspension 1250 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121076616", "ndc_label_name": "Calcium Carbonate Antacid Suspension 1250 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121476605", "ndc_label_name": "Calcium Carbonate Antacid Suspension 1250 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00054311763", "ndc_label_name": "Calcium Carbonate Antacid Suspension 1250 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896076315", "ndc_label_name": "Calcium Carbonate Antacid Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "57896076201", "ndc_label_name": "Calcium Carbonate Antacid Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904598561", "ndc_label_name": "Calcium Carbonate Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "69618002015", "ndc_label_name": "Calcium Carbonate Antacid TABLET CHEWABLE 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00761081112", "ndc_label_name": "Calcium Carbonate TABLET 1500 (600 Ca) MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904323261", "ndc_label_name": "Calcium Carbonate Tablet 1500 (600 Ca) MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40986002076", "ndc_label_name": "Calcium Carbonate TABLET 1500 (600 Ca) MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904323252", "ndc_label_name": "Calcium Carbonate Tablet 1500 (600 Ca) MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904323292", "ndc_label_name": "Calcium Carbonate Tablet 1500 (600 Ca) MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50268014913", "ndc_label_name": "Calcium Carbonate TABLET CHEWABLE 1250 (500 Ca) MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629068701", "ndc_label_name": "Calcium Carbonate Tablet Chewable 1250 (500 Ca) MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50268014911", "ndc_label_name": "Calcium Carbonate Tablet Chewable 1250 (500 Ca) MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917011335", "ndc_label_name": "Calcium Citrate + D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007539", "ndc_label_name": "Calcium Citrate + D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58526000539", "ndc_label_name": "Calcium Citrate + D3 Maximum TABLET 315-250 MG-UNIT Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50268014715", "ndc_label_name": "Calcium Citrate + D3 Maximum Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985027495", "ndc_label_name": "Calcium Citrate + D3 Maximum Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985027494", "ndc_label_name": "Calcium Citrate + D3 Maximum Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985027493", "ndc_label_name": "Calcium Citrate + D3 Maximum Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "77333011325", "ndc_label_name": "Calcium Citrate + D3 Maximum Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50268014711", "ndc_label_name": "Calcium Citrate + D3 Maximum Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "77333011310", "ndc_label_name": "Calcium Citrate + D3 Maximum Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985027492", "ndc_label_name": "Calcium Citrate + D3 Maximum Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917017177", "ndc_label_name": "Calcium Citrate + D3 Tablet 200-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985022332", "ndc_label_name": "Calcium Citrate +D Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58487002842", "ndc_label_name": "Calcium Citrate TABLET 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58487002841", "ndc_label_name": "Calcium Citrate TABLET 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58487002843", "ndc_label_name": "Calcium Citrate TABLET 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "43292055606", "ndc_label_name": "Calcium Citrate TABLET 250 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917005014", "ndc_label_name": "Calcium Citrate Tablet 950 (200 Ca) MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917007538", "ndc_label_name": "Calcium Citrate Tablet 950 (200 Ca) MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985022318", "ndc_label_name": "Calcium Citrate Tablet 950 (200 Ca) MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35046000155", "ndc_label_name": "Calcium Citrate Tablet 950 (200 Ca) MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00182415101", "ndc_label_name": "Calcium Citrate TABLET 950 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012702", "ndc_label_name": "Calcium Citrate+D3 Petites Tablet 200-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917016630", "ndc_label_name": "Calcium Citrate+D3 Petites Tablet 200-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40985027709", "ndc_label_name": "Calcium Citrate+D3 Petites Tablet 200-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917014587", "ndc_label_name": "Calcium Citrate+D3 Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629168601", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 200-3.125 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00761015832", "ndc_label_name": "Calcium Citrate-Vitamin D TABLET 315-200 MG-UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917005016", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "07610015832", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629077402", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845012375", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54629077401", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10006073037", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "31604001475", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "10006070044", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917005015", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11845012377", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-5 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864073406", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "74312007510", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "30768003554", "ndc_label_name": "Calcium Citrate-Vitamin D Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "81131004597", "ndc_label_name": "Calcium Citrate-Vitamin D3 Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "35046000154", "ndc_label_name": "Calcium Citrate-Vitamin D3 Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012770", "ndc_label_name": "Calcium Citrate-Vitamin D3 Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "96295012819", "ndc_label_name": "Calcium Citrate-Vitamin D3 Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "80830236209", "ndc_label_name": "Calcium Gluconate-NaCl Solution 1-0.675 GM/50ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567062024", "ndc_label_name": "Calcium Gluconate-NaCl Solution 1-0.675 GM/50ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567062001", "ndc_label_name": "Calcium Gluconate-NaCl Solution 1-0.675 GM/50ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65219016201", "ndc_label_name": "Calcium Gluconate-NaCl Solution 1-0.675 GM/50ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65219016210", "ndc_label_name": "Calcium Gluconate-NaCl Solution 1-0.675 GM/50ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "80830236202", "ndc_label_name": "Calcium Gluconate-NaCl Solution 1-0.675 GM/50ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "80830236201", "ndc_label_name": "Calcium Gluconate-NaCl Solution 1-0.675 GM/50ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65219016401", "ndc_label_name": "Calcium Gluconate-NaCl Solution 2-0.675 GM/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "80830236309", "ndc_label_name": "Calcium Gluconate-NaCl Solution 2-0.675 GM/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567062124", "ndc_label_name": "Calcium Gluconate-NaCl Solution 2-0.675 GM/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "80830236302", "ndc_label_name": "Calcium Gluconate-NaCl Solution 2-0.675 GM/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567062101", "ndc_label_name": "Calcium Gluconate-NaCl Solution 2-0.675 GM/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65219016450", "ndc_label_name": "Calcium Gluconate-NaCl Solution 2-0.675 GM/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "80830236301", "ndc_label_name": "Calcium Gluconate-NaCl Solution 2-0.675 GM/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58487001512", "ndc_label_name": "Calcium Pantothenate TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58487001511", "ndc_label_name": "Calcium Pantothenate TABLET 500 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536671701", "ndc_label_name": "Calcium Pantothenate Tablet 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "66220028422", "ndc_label_name": "Caldolor Solution 800 MG/200ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66220028411", "ndc_label_name": "Caldolor Solution 800 MG/200ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66220028708", "ndc_label_name": "Caldolor SOLUTION 800 MG/8ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59528033102", "ndc_label_name": "Calphron TABLET 667 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00310051260", "ndc_label_name": "Calquence Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310351260", "ndc_label_name": "Calquence Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "81877063060", "ndc_label_name": "Calsodore Kit 0.005 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69448001463", "ndc_label_name": "Camcevi Prefilled Syringe 42 MG Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862088401", "ndc_label_name": "Camila Tablet 0.35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862010201", "ndc_label_name": "Camila Tablet 0.35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862010206", "ndc_label_name": "Camila Tablet 0.35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862088403", "ndc_label_name": "Camila Tablet 0.35 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009752903", "ndc_label_name": "Camptosar SOLUTION 100 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009752905", "ndc_label_name": "Camptosar Solution 300 MG/15ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009752904", "ndc_label_name": "Camptosar SOLUTION 40 MG/2ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093614891", "ndc_label_name": "Camrese Lo TABLET 0.1-0.02 & 0.01 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093614882", "ndc_label_name": "Camrese Lo TABLET 0.1-0.02 & 0.01 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093313491", "ndc_label_name": "Camrese TABLET 0.15-0.03 &0.01 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093313482", "ndc_label_name": "Camrese TABLET 0.15-0.03 &0.01 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "73625011311", "ndc_label_name": "Camzyos Capsule 10 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73625011411", "ndc_label_name": "Camzyos Capsule 15 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73625011111", "ndc_label_name": "Camzyos Capsule 2.5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73625011211", "ndc_label_name": "Camzyos Capsule 5 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58914050156", "ndc_label_name": "Canasa Suppository 1000 MG Rectal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58914050142", "ndc_label_name": "Canasa Suppository 1000 MG Rectal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687024125", "ndc_label_name": "Candesartan Cilexetil Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505362003", "ndc_label_name": "Candesartan Cilexetil Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781593831", "ndc_label_name": "Candesartan Cilexetil Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781593892", "ndc_label_name": "Candesartan Cilexetil Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342011610", "ndc_label_name": "Candesartan Cilexetil TABLET 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378323177", "ndc_label_name": "Candesartan Cilexetil Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378323193", "ndc_label_name": "Candesartan Cilexetil Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505362009", "ndc_label_name": "Candesartan Cilexetil Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884066009", "ndc_label_name": "Candesartan Cilexetil TABLET 16 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342011607", "ndc_label_name": "Candesartan Cilexetil TABLET 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332034390", "ndc_label_name": "Candesartan Cilexetil Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687024195", "ndc_label_name": "Candesartan Cilexetil Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332034330", "ndc_label_name": "Candesartan Cilexetil Tablet 16 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687013095", "ndc_label_name": "Candesartan Cilexetil Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342011710", "ndc_label_name": "Candesartan Cilexetil TABLET 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378323277", "ndc_label_name": "Candesartan Cilexetil Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378323293", "ndc_label_name": "Candesartan Cilexetil Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505362109", "ndc_label_name": "Candesartan Cilexetil Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781593931", "ndc_label_name": "Candesartan Cilexetil Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505362103", "ndc_label_name": "Candesartan Cilexetil Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884066109", "ndc_label_name": "Candesartan Cilexetil TABLET 32 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332006090", "ndc_label_name": "Candesartan Cilexetil TABLET 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687013025", "ndc_label_name": "Candesartan Cilexetil Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332006030", "ndc_label_name": "Candesartan Cilexetil TABLET 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781593992", "ndc_label_name": "Candesartan Cilexetil Tablet 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342011707", "ndc_label_name": "Candesartan Cilexetil TABLET 32 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781593631", "ndc_label_name": "Candesartan Cilexetil Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342011407", "ndc_label_name": "Candesartan Cilexetil TABLET 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378322477", "ndc_label_name": "Candesartan Cilexetil Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884065809", "ndc_label_name": "Candesartan Cilexetil TABLET 4 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342011410", "ndc_label_name": "Candesartan Cilexetil Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332034130", "ndc_label_name": "Candesartan Cilexetil Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378322493", "ndc_label_name": "Candesartan Cilexetil Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505361803", "ndc_label_name": "Candesartan Cilexetil Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332034190", "ndc_label_name": "Candesartan Cilexetil Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342011510", "ndc_label_name": "Candesartan Cilexetil Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49884065909", "ndc_label_name": "Candesartan Cilexetil TABLET 8 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505361903", "ndc_label_name": "Candesartan Cilexetil Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378322577", "ndc_label_name": "Candesartan Cilexetil Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342011507", "ndc_label_name": "Candesartan Cilexetil TABLET 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378322593", "ndc_label_name": "Candesartan Cilexetil Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781593731", "ndc_label_name": "Candesartan Cilexetil Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687011925", "ndc_label_name": "Candesartan Cilexetil Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332034230", "ndc_label_name": "Candesartan Cilexetil Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687011995", "ndc_label_name": "Candesartan Cilexetil Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332034290", "ndc_label_name": "Candesartan Cilexetil Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342013115", "ndc_label_name": "Candesartan Cilexetil-HCTZ TABLET 16-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559066090", "ndc_label_name": "Candesartan Cilexetil-HCTZ Tablet 16-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505375809", "ndc_label_name": "Candesartan Cilexetil-HCTZ Tablet 16-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378300177", "ndc_label_name": "Candesartan Cilexetil-HCTZ TABLET 16-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378300105", "ndc_label_name": "Candesartan Cilexetil-HCTZ Tablet 16-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342013110", "ndc_label_name": "Candesartan Cilexetil-HCTZ TABLET 16-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378300277", "ndc_label_name": "Candesartan Cilexetil-HCTZ TABLET 32-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342013210", "ndc_label_name": "Candesartan Cilexetil-HCTZ TABLET 32-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378300205", "ndc_label_name": "Candesartan Cilexetil-HCTZ Tablet 32-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342013215", "ndc_label_name": "Candesartan Cilexetil-HCTZ TABLET 32-12.5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505375909", "ndc_label_name": "Candesartan Cilexetil-HCTZ Tablet 32-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559066190", "ndc_label_name": "Candesartan Cilexetil-HCTZ Tablet 32-12.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378300305", "ndc_label_name": "Candesartan Cilexetil-HCTZ Tablet 32-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378300377", "ndc_label_name": "Candesartan Cilexetil-HCTZ TABLET 32-25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342013310", "ndc_label_name": "Candesartan Cilexetil-HCTZ TABLET 32-25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559066290", "ndc_label_name": "Candesartan Cilexetil-HCTZ Tablet 32-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342013315", "ndc_label_name": "Candesartan Cilexetil-HCTZ TABLET 32-25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505376009", "ndc_label_name": "Candesartan Cilexetil-HCTZ Tablet 32-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729007212", "ndc_label_name": "Capecitabine TABLET 150 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378251191", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093747306", "ndc_label_name": "Capecitabine TABLET 150 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407009560", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291016660", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72205000660", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054027121", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714046701", "ndc_label_name": "Capecitabine TABLET 150 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980027606", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877045860", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291019060", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651020460", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756023886", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097094903", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162084306", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485020460", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72606055401", "ndc_label_name": "Capecitabine Tablet 150 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687014911", "ndc_label_name": "Capecitabine TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687014994", "ndc_label_name": "Capecitabine TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054027223", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093747489", "ndc_label_name": "Capecitabine TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378251278", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714046801", "ndc_label_name": "Capecitabine TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291019112", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291016712", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980027712", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877045912", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407009612", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268015413", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079051005", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729007329", "ndc_label_name": "Capecitabine TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756023920", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268015411", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59651020508", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079051001", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72205000792", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097094808", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162084416", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72606055501", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485020512", "ndc_label_name": "Capecitabine Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00299550004", "ndc_label_name": "Capex Shampoo 0.01 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72060011040", "ndc_label_name": "Caplyta Capsule 10.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72060012140", "ndc_label_name": "Caplyta Capsule 21 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72060014230", "ndc_label_name": "Caplyta Capsule 42 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72060014240", "ndc_label_name": "Caplyta Capsule 42 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58468782003", "ndc_label_name": "Caprelsa Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310782030", "ndc_label_name": "Caprelsa Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58468784003", "ndc_label_name": "Caprelsa Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00310784030", "ndc_label_name": "Caprelsa Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70645002512", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959059503", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50488102502", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959081502", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70645002550", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536252525", "ndc_label_name": "Capsaicin CREAM 0.025 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959025702", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49999040960", "ndc_label_name": "Capsaicin CREAM 0.025 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50488102505", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50090229300", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52959025703", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70645002525", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54569433200", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50488102501", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63874086260", "ndc_label_name": "Capsaicin Cream 0.025 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50268019657", "ndc_label_name": "Capsaicin Cream 0.075 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50488107501", "ndc_label_name": "Capsaicin Cream 0.075 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50488106006", "ndc_label_name": "Capsaicin HP Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11917006938", "ndc_label_name": "Capsaicin HP CREAM 0.1 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "69375000660", "ndc_label_name": "Capsaicin HP Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000054901", "ndc_label_name": "Capsaicin Pain Relief Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "81533020015", "ndc_label_name": "Capsaid ES Arthritis Relief Cream 0.1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63629170601", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378302201", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034910", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143117401", "ndc_label_name": "Captopril TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034901", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053630", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69292052850", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781808001", "ndc_label_name": "Captopril TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629170603", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034930", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053660", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69292052801", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629170602", "ndc_label_name": "Captopril Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645016359", "ndc_label_name": "Captopril TABLET 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781805201", "ndc_label_name": "Captopril TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143117110", "ndc_label_name": "Captopril TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378300710", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723094", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687030421", "ndc_label_name": "Captopril TABLET 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143117101", "ndc_label_name": "Captopril TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723092", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723060", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629289601", "ndc_label_name": "Captopril TABLET 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687030411", "ndc_label_name": "Captopril TABLET 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217000360", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217000300", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544015060", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378300701", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781805210", "ndc_label_name": "Captopril TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723090", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645016059", "ndc_label_name": "Captopril TABLET 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544015073", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569459300", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217000390", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69292052201", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079086301", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079086320", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904504561", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569459303", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544015045", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217000330", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063014630", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69292052210", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544015092", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569459301", "ndc_label_name": "Captopril Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143117210", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143117201", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097430", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097400", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097460", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723191", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378301201", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723160", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781806101", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378301210", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097490", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079086401", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999010560", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723192", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723130", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723190", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904504661", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002043130", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034730", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864006628", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090184003", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629133801", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999010500", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723194", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999010510", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002043160", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034742", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034702", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002043100", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569424604", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569424600", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781806110", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999010530", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687031521", "ndc_label_name": "Captopril TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645016159", "ndc_label_name": "Captopril TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034705", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569424603", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69292052401", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569424605", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079086420", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687031511", "ndc_label_name": "Captopril TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034740", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289034430", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569424607", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629133802", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034745", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289034490", "ndc_label_name": "Captopril TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760030330", "ndc_label_name": "Captopril TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629133803", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69292052410", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034701", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034720", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034790", "ndc_label_name": "Captopril Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723230", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723291", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378301710", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261018230", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723294", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143117301", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289021290", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723292", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723290", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569424704", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781807501", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999051160", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781807510", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143117310", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034801", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261018200", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569424700", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289021230", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904504761", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569424702", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629254103", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378301701", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034810", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261018260", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569424703", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723260", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261018290", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629254104", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034814", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629254102", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645016259", "ndc_label_name": "Captopril TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999051130", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760030230", "ndc_label_name": "Captopril TABLET 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034820", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002108600", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034860", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69292052601", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034890", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002108603", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69292052610", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002108606", "ndc_label_name": "Captopril TABLET 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629254101", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874034830", "ndc_label_name": "Captopril Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378008101", "ndc_label_name": "Captopril-hydroCHLOROthiazide Tablet 25-15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378008301", "ndc_label_name": "Captopril-hydroCHLOROthiazide Tablet 25-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378008401", "ndc_label_name": "Captopril-hydroCHLOROthiazide Tablet 50-15 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378008601", "ndc_label_name": "Captopril-hydroCHLOROthiazide Tablet 50-25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00006434702", "ndc_label_name": "Capvaxive Solution Prefilled Syringe 0.5 ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00006434701", "ndc_label_name": "Capvaxive Solution Prefilled Syringe 0.5 ML Intramuscular", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "41167075142", "ndc_label_name": "Capzasin-HP CREAM 0.1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "41167075146", "ndc_label_name": "Capzasin-HP Cream 0.1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "72847031620", "ndc_label_name": "Capzix Cream 0.1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "52276031205", "ndc_label_name": "Carbaglu Tablet Soluble 200 MG Oral", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52276031260", "ndc_label_name": "Carbaglu Tablet Soluble 200 MG Oral", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "29033001912", "ndc_label_name": "CarBAMazepine ER Capsule Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093551289", "ndc_label_name": "CarBAMazepine ER Capsule Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505280507", "ndc_label_name": "CarBAMazepine ER CAPSULE EXTENDED RELEASE 12 HOUR 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672415101", "ndc_label_name": "CarBAMazepine ER CAPSULE EXTENDED RELEASE 12 HOUR 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993040732", "ndc_label_name": "CarBAMazepine ER CAPSULE EXTENDED RELEASE 12 HOUR 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093551389", "ndc_label_name": "CarBAMazepine ER Capsule Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29033002012", "ndc_label_name": "CarBAMazepine ER Capsule Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993040832", "ndc_label_name": "CarBAMazepine ER CAPSULE EXTENDED RELEASE 12 HOUR 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672415001", "ndc_label_name": "CarBAMazepine ER CAPSULE EXTENDED RELEASE 12 HOUR 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569662100", "ndc_label_name": "CarBAMazepine ER Capsule Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505280607", "ndc_label_name": "CarBAMazepine ER CAPSULE EXTENDED RELEASE 12 HOUR 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505280707", "ndc_label_name": "CarBAMazepine ER CAPSULE EXTENDED RELEASE 12 HOUR 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29033000412", "ndc_label_name": "CarBAMazepine ER Capsule Extended Release 12 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093551489", "ndc_label_name": "CarBAMazepine ER Capsule Extended Release 12 Hour 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66993040932", "ndc_label_name": "CarBAMazepine ER CAPSULE EXTENDED RELEASE 12 HOUR 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672414901", "ndc_label_name": "CarBAMazepine ER CAPSULE EXTENDED RELEASE 12 HOUR 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781598601", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781801601", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672412301", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084056111", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781598701", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672412401", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084056121", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084056221", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781598801", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672412501", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084056211", "ndc_label_name": "CarBAMazepine ER Tablet Extended Release 12 Hour 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60432012916", "ndc_label_name": "CarBAMazepine SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68094000762", "ndc_label_name": "CarBAMazepine Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672404709", "ndc_label_name": "CarBAMazepine SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68094000859", "ndc_label_name": "CarBAMazepine Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68094030159", "ndc_label_name": "CarBAMazepine Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68094000862", "ndc_label_name": "CarBAMazepine Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68094000759", "ndc_label_name": "CarBAMazepine Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68094021459", "ndc_label_name": "CarBAMazepine Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68094030162", "ndc_label_name": "CarBAMazepine Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68094021462", "ndc_label_name": "CarBAMazepine Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62135086724", "ndc_label_name": "carBAMazepine Suspension 200 MG/10ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62135086759", "ndc_label_name": "carBAMazepine Suspension 200 MG/10ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999061600", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723691", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093010901", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904617261", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723628", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723620", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093010910", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261067602", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999061690", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904617250", "ndc_label_name": "CarBAMazepine TABLET 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723690", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668026805", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668026801", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407021501", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261067620", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261067607", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569265501", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261067614", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668026810", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063032812", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672400501", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672400503", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063032830", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261067690", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569265503", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261067621", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999061601", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353095330", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544058332", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569905900", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090216103", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353095353", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289021030", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261067628", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999061660", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079038501", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084044411", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864084330", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569265500", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353095380", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267027890", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261067630", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090216100", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429003210", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205002590", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505018301", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505018300", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090216101", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544058360", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261067660", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079038519", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629401801", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069101", "ndc_label_name": "CarBAMazepine TABLET 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788721008", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629401802", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090269700", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788721001", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353095360", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672400502", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049204", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610033660", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436341503", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049201", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049220", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788721002", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079038517", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429003201", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049230", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610033653", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079038520", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049210", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049245", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610033680", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407021510", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049290", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049260", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788721006", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569265505", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610033630", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049202", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267027891", "ndc_label_name": "CarBAMazepine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049240", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544058353", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788721003", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544058380", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084044401", "ndc_label_name": "carBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788721009", "ndc_label_name": "CarBAMazepine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079087020", "ndc_label_name": "carBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672404102", "ndc_label_name": "CarBAMazepine TABLET CHEWABLE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723590", "ndc_label_name": "carBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723591", "ndc_label_name": "carBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687047911", "ndc_label_name": "carBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093077801", "ndc_label_name": "carBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687047901", "ndc_label_name": "carBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668027101", "ndc_label_name": "CarBAMazepine TABLET CHEWABLE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429093405", "ndc_label_name": "CarBAMazepine TABLET CHEWABLE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723528", "ndc_label_name": "carBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079087001", "ndc_label_name": "carBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999078201", "ndc_label_name": "CarBAMazepine TABLET CHEWABLE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569279501", "ndc_label_name": "CarBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00615451543", "ndc_label_name": "CarBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672404101", "ndc_label_name": "CarBAMazepine TABLET CHEWABLE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904385461", "ndc_label_name": "CarBAMazepine TABLET CHEWABLE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904385480", "ndc_label_name": "carBAMazepine Tablet Chewable 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668027105", "ndc_label_name": "CarBAMazepine TABLET CHEWABLE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51672405001", "ndc_label_name": "carBAMazepine Tablet Chewable 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54092017112", "ndc_label_name": "Carbatrol Capsule Extended Release 12 Hour 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54092017212", "ndc_label_name": "Carbatrol Capsule Extended Release 12 Hour 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54092017312", "ndc_label_name": "Carbatrol Capsule Extended Release 12 Hour 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407015801", "ndc_label_name": "Carbidopa Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714006701", "ndc_label_name": "Carbidopa Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42799012301", "ndc_label_name": "Carbidopa TABLET 25 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43975022010", "ndc_label_name": "Carbidopa Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47781033201", "ndc_label_name": "Carbidopa Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68682020025", "ndc_label_name": "Carbidopa Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59651014601", "ndc_label_name": "Carbidopa Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43386098001", "ndc_label_name": "Carbidopa Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079097801", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084028101", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079097820", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729007817", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378008801", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353032709", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729007801", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084028111", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001017100", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756046188", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729007901", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729007917", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756045788", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378009401", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079092301", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001017200", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544067251", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544067260", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079092320", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544067280", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084028201", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084028211", "ndc_label_name": "Carbidopa-Levodopa ER Tablet Extended Release 50-200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756051713", "ndc_label_name": "Carbidopa-Levodopa TABLET 10-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999099860", "ndc_label_name": "Carbidopa-Levodopa TABLET 10-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261071930", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862007701", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228253810", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228253850", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868286601", "ndc_label_name": "Carbidopa-Levodopa TABLET 10-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093029205", "ndc_label_name": "Carbidopa-Levodopa TABLET 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261071990", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429065001", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862085505", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862007705", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356062860", "ndc_label_name": "Carbidopa-Levodopa TABLET 10-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378007801", "ndc_label_name": "Carbidopa-Levodopa TABLET 10-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739004610", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429015201", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407016601", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407016605", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569649100", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862085501", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429065005", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756051788", "ndc_label_name": "Carbidopa-Levodopa TABLET 10-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739010710", "ndc_label_name": "Carbidopa-Levodopa Tablet 10-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353060480", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093029301", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093029305", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862007910", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353060460", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378008501", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228253910", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093029310", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569498801", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353051060", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228253950", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756051818", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090341901", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407016701", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00615356143", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904623761", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739004710", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353051080", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228253996", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756051888", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436675302", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862007901", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353020260", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261072030", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739010810", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079088401", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079075601", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610026980", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079075620", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429015310", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353020280", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261072090", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756051813", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862085601", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407016705", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079088420", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610026960", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084009301", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862085605", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862007905", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429015301", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55154148400", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429065105", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862085610", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739001710", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429065101", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084009311", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093029405", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093029401", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700064230", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999099960", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407016801", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407016805", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429015401", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093029410", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228254096", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228254050", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862008001", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862085810", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378113301", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862008005", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862008010", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00228254010", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756051913", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862085801", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429065201", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429015405", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084009401", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739004810", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904623861", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429065205", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356062960", "ndc_label_name": "Carbidopa-Levodopa TABLET 25-250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756051988", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862085805", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739001310", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084009411", "ndc_label_name": "Carbidopa-Levodopa Tablet 25-250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335018688", "ndc_label_name": "Carbidopa-Levodopa Tablet Dispersible 10-100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378505101", "ndc_label_name": "Carbidopa-Levodopa Tablet Dispersible 10-100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335018788", "ndc_label_name": "Carbidopa-Levodopa Tablet Dispersible 25-100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378505201", "ndc_label_name": "Carbidopa-Levodopa Tablet Dispersible 25-100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378505301", "ndc_label_name": "Carbidopa-Levodopa Tablet Dispersible 25-250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335018888", "ndc_label_name": "Carbidopa-Levodopa Tablet Dispersible 25-250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64679078204", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 12.5-50-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378830001", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 12.5-50-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335000188", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 12.5-50-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781561301", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 12.5-50-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16571069001", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 18.75-200-75 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16571069001", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 18.75-75-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378830101", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 18.75-75-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335000288", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 18.75-75-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781562501", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 18.75-75-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64679078304", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 18.75-75-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378830201", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 25-100-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335000388", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 25-100-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781563701", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 25-100-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64679078404", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 25-100-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781564101", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 31.25-125-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335000488", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 31.25-125-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64679078504", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 31.25-125-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378830301", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 31.25-125-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335000588", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 37.5-150-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378830401", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 37.5-150-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781565401", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 37.5-150-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64679078604", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 37.5-150-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378830501", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 50-200-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64679078704", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 50-200-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47335000688", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 50-200-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781566901", "ndc_label_name": "Carbidopa-Levodopa-Entacapone Tablet 50-200-200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16729029533", "ndc_label_name": "CARBOplatin Solution 150 MG/15ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703424601", "ndc_label_name": "CARBOplatin SOLUTION 150 MG/15ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54288016501", "ndc_label_name": "CARBOplatin Solution 150 MG/15ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703424681", "ndc_label_name": "CARBOplatin SOLUTION 150 MG/15ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61703033922", "ndc_label_name": "CARBOplatin SOLUTION 150 MG/15ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288010015", "ndc_label_name": "CARBOplatin Solution 150 MG/15ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742044615", "ndc_label_name": "CARBOplatin Solution 150 MG/15ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505628203", "ndc_label_name": "CARBOplatin Solution 150 MG/15ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61703015005", "ndc_label_name": "CARBOplatin Solution 150 MG/15ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703424401", "ndc_label_name": "CARBOplatin SOLUTION 50 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54288016401", "ndc_label_name": "CARBOplatin Solution 50 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703424481", "ndc_label_name": "CARBOplatin SOLUTION 50 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505628201", "ndc_label_name": "CARBOplatin Solution 50 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729029531", "ndc_label_name": "CARBOplatin Solution 50 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288010005", "ndc_label_name": "CARBOplatin Solution 50 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742044505", "ndc_label_name": "CARBOplatin Solution 50 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61703033918", "ndc_label_name": "CARBOplatin SOLUTION 50 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61703036018", "ndc_label_name": "CARBOplatin Solution 50 MG/5ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703423901", "ndc_label_name": "CARBOplatin SOLUTION 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335028440", "ndc_label_name": "CARBOplatin SOLUTION 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61703033956", "ndc_label_name": "CARBOplatin SOLUTION 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61703060005", "ndc_label_name": "CARBOplatin Solution 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729029512", "ndc_label_name": "CARBOplatin SOLUTION 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703423981", "ndc_label_name": "CARBOplatin SOLUTION 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288010051", "ndc_label_name": "CARBOplatin Solution 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323017260", "ndc_label_name": "CARBOplatin SOLUTION 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50742044860", "ndc_label_name": "CARBOplatin Solution 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54288016701", "ndc_label_name": "CARBOplatin Solution 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150038601", "ndc_label_name": "CARBOplatin Solution 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505628207", "ndc_label_name": "CARBOplatin Solution 600 MG/60ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "08525010801", "ndc_label_name": "CardioCom Lancing Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00187079542", "ndc_label_name": "Cardizem CD CAPSULE EXTENDED RELEASE 24 HOUR 120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187079530", "ndc_label_name": "Cardizem CD CAPSULE EXTENDED RELEASE 24 HOUR 120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356051030", "ndc_label_name": "Cardizem CD CAPSULE EXTENDED RELEASE 24 HOUR 120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187079630", "ndc_label_name": "Cardizem CD CAPSULE EXTENDED RELEASE 24 HOUR 180 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187079642", "ndc_label_name": "Cardizem CD CAPSULE EXTENDED RELEASE 24 HOUR 180 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187079742", "ndc_label_name": "Cardizem CD CAPSULE EXTENDED RELEASE 24 HOUR 240 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187079730", "ndc_label_name": "Cardizem CD CAPSULE EXTENDED RELEASE 24 HOUR 240 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187079830", "ndc_label_name": "Cardizem CD Capsule Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187079842", "ndc_label_name": "Cardizem CD Capsule Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187079942", "ndc_label_name": "Cardizem CD CAPSULE EXTENDED RELEASE 24 HOUR 360 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187204530", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187204590", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187204630", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 180 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187204690", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 180 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00074306290", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 240 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187204790", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 240 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187204730", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 240 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187204890", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187204830", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187204930", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 360 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187204990", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 360 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187205030", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 420 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187205090", "ndc_label_name": "Cardizem LA Tablet Extended Release 24 Hour 420 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187079247", "ndc_label_name": "Cardizem TABLET 120 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187077147", "ndc_label_name": "Cardizem TABLET 30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64455077155", "ndc_label_name": "Cardizem TABLET 30 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00187077247", "ndc_label_name": "Cardizem TABLET 60 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00049275066", "ndc_label_name": "Cardura Tablet 1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00049276066", "ndc_label_name": "Cardura Tablet 2 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66116018930", "ndc_label_name": "Cardura Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00049277066", "ndc_label_name": "Cardura Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864086030", "ndc_label_name": "Cardura Tablet 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00049278066", "ndc_label_name": "Cardura Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289058430", "ndc_label_name": "Cardura Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864085630", "ndc_label_name": "Cardura Tablet 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00049271030", "ndc_label_name": "Cardura XL Tablet Extended Release 24 Hour 4 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00049272030", "ndc_label_name": "Cardura XL Tablet Extended Release 24 Hour 8 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "08214070721", "ndc_label_name": "CareOne Advanced Lancing Dev", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08396500244", "ndc_label_name": "CareOne Blood Glucose System KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08396500144", "ndc_label_name": "CareOne Blood Glucose System KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08396500444", "ndc_label_name": "CareOne Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08396500544", "ndc_label_name": "CareOne Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08396500644", "ndc_label_name": "CareOne Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08396500844", "ndc_label_name": "CareOne Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08396500744", "ndc_label_name": "CareOne Blood Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08214035721", "ndc_label_name": "CareOne Lancet Super Thin 30G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08214015721", "ndc_label_name": "CareOne Lancet Thin 23G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08617155572", "ndc_label_name": "CareSens Control A SOLUTION IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "32671000254", "ndc_label_name": "CareSens Control A SOLUTION In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "10011073008", "ndc_label_name": "CareSens Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "85325000168", "ndc_label_name": "CareSens N Feliz BT Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "85325000169", "ndc_label_name": "CareSens N Feliz Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08617164301", "ndc_label_name": "CareSens N Glucose System DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08617155264", "ndc_label_name": "CareSens N Glucose System DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08617164104", "ndc_label_name": "CareSens N Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08617155104", "ndc_label_name": "CareSens N Glucose Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "08617164442", "ndc_label_name": "CareSens N Voice System DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50010022431", "ndc_label_name": "Carestart COVID-19 Home Test Kit In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393040020", "ndc_label_name": "CareTouch Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393040030", "ndc_label_name": "CareTouch Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393040040", "ndc_label_name": "CareTouch Alcohol Prep Pad 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393040010", "ndc_label_name": "CareTouch Alcohol Prep PAD 70 %", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393090101", "ndc_label_name": "CareTouch BP Arm Monitor DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393090201", "ndc_label_name": "CareTouch BP Wrist Monitor DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393020100", "ndc_label_name": "CareTouch Lancing/Ejector", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393021020", "ndc_label_name": "CareTouch Monitor System Kit w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393017101", "ndc_label_name": "CareTouch Safety Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393017201", "ndc_label_name": "CareTouch Safety Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393016901", "ndc_label_name": "CareTouch Safety Lancets 26G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393021105", "ndc_label_name": "CareTouch Test Strip In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393014901", "ndc_label_name": "CareTouch Twist Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393015001", "ndc_label_name": "CareTouch Twist Lancets 30G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "70393015201", "ndc_label_name": "CareTouch Twist Lancets 33G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "35573045960", "ndc_label_name": "Carglumic Acid Tablet Soluble 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71863011460", "ndc_label_name": "Carglumic Acid Tablet Soluble 200 MG Oral", "drug_tier": "Tier 3", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44206041892", "ndc_label_name": "Carimune NF Solution Reconstituted 12 GM Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44206041812", "ndc_label_name": "Carimune NF Solution Reconstituted 12 GM Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44206041706", "ndc_label_name": "Carimune NF Solution Reconstituted 6 GM Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44206041791", "ndc_label_name": "Carimune NF Solution Reconstituted 6 GM Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980038001", "ndc_label_name": "Carisoprodol Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51525590101", "ndc_label_name": "Carisoprodol Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "29033020701", "ndc_label_name": "Carisoprodol Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42543043401", "ndc_label_name": "Carisoprodol Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52536068210", "ndc_label_name": "Carisoprodol TABLET 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862069301", "ndc_label_name": "Carisoprodol TABLET 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001603", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603258228", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00143117601", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544013230", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591551301", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723840", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723820", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723830", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001690", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "12634043712", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "12634043760", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001602", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544003330", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723891", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591551310", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723890", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038702", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714051001", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001607", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001628", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001612", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603258221", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714051003", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591551305", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038714", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001625", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001614", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038707", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038728", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781500505", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001600", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00603258232", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038740", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001640", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001621", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038712", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42543070005", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "12634043771", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001624", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781500501", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038750", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038700", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038725", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006400", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030201", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714051002", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001630", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "12634043790", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006401", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038721", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006460", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006450", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030210", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001620", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001636", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001650", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006430", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038760", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356072101", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356072160", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030215", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038703", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038730", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001660", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006490", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006420", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356073440", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356073401", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030221", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038720", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038790", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038724", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356072190", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356073430", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356073460", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356073420", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030298", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261038736", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006415", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356072120", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030224", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356073490", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356080530", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356080501", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353010260", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030220", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356072130", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42543070001", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063082490", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030230", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030260", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063082414", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090277105", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030240", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356072140", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030214", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006401", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063082415", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063030290", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090304809", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090323205", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353010230", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356080560", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090253000", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006407", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353010253", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063082430", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436258202", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436045101", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228010901", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356080590", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228010910", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090253009", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353010270", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006418", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436343501", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436045102", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436070504", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42543070010", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436109002", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090321108", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353079160", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006460", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002620", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436070502", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436109001", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353079153", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436343504", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436258203", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090253008", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090253003", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002630", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436109004", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436109003", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353079170", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002610", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436258204", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090321100", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436045103", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002652", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436258201", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002600", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999006406", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002632", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002606", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090321103", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436045104", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015260", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002612", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002603", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090321109", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002690", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015808", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436070503", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436070501", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015890", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002625", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002614", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090323200", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002035630", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569170900", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436343502", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436343503", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004930", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002660", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002624", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50228010905", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015216", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004920", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002621", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50742065601", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004960", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015816", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002650", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50742065605", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015290", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004921", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002640", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002628", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700045160", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569170903", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015230", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002615", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015802", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700062330", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015202", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002656", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700062301", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569170909", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015830", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002645", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569170907", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700077030", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015245", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569170901", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700077001", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569340300", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004924", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959002680", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569340304", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118017409", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015860", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569170904", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746070501", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569340305", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700045120", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015208", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569340309", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746070505", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569170902", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569340301", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919003930", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004914", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700083601", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015845", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004901", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187011360", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569170908", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004940", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919076872", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004998", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050810", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004910", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004990", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187011390", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61442045110", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700062390", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919087872", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700083630", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919076830", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289004915", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700045101", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187078690", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919003920", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700077090", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919097990", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700083690", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919076890", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700045190", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700045130", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130810", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130805", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61442045105", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756044602", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118017403", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919087890", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700062360", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700045140", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629470703", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130806", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919003940", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130801", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118017406", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187078630", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700077060", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58657064501", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629470704", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033015", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919003960", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629470701", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58657064510", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629438902", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700083660", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58657064550", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033056", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033018", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919003972", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629470702", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760011060", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033074", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118017407", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429050801", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862015805", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033024", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919097930", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033028", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919087830", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033075", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746070510", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760039790", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004356", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033030", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919097960", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033040", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187011330", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033080", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760011090", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760070530", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071200406", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033042", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756044604", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033050", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130802", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862015801", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919003990", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61442045101", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686600", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033045", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62756044605", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66116022430", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130807", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862015899", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629438905", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919076860", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686605", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66116062730", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187011372", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544001253", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130808", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004340", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629438906", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130803", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69584011110", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004320", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130800", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544028370", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033005", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544001260", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033001", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130804", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013103", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004345", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629130809", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686603", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033012", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205024130", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033060", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629438903", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013108", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004360", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629438901", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013104", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033072", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205033990", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66116061320", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629438904", "ndc_label_name": "Carisoprodol TABLET 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013109", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004390", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033002", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013105", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033077", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013102", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004330", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63739004910", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335040701", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004391", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033007", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335040705", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980017405", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335051602", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544001270", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033003", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335040702", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544028330", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033011", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335040706", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980017410", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069302", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686602", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033004", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335040704", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544028353", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033014", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069300", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004312", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069303", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013100", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033010", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335040709", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686608", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033020", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009753", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544001230", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069308", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013101", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033016", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069304", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69584011190", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033025", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72789001630", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084038001", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335120305", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013106", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033021", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72789001990", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335040703", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004315", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033084", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788258203", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009760", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069301", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874033090", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788258206", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335051605", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267100700", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980017401", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788258209", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335051608", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069306", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004384", "ndc_label_name": "Carisoprodol TABLET 350 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686609", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084038011", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544028360", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686606", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205024190", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335051600", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069307", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335051603", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335051601", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335051606", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788686601", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335051609", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335051604", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069309", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335120307", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009730", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335051607", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009770", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335013107", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72789001995", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335069305", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72789001901", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335040700", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "72789001998", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335040707", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335040708", "ndc_label_name": "Carisoprodol Tablet 350 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185072401", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155014501", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045460", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185072405", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723920", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440723940", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64980017501", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289069528", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045402", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289069540", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959045414", "ndc_label_name": "Carisoprodol-Aspirin Tablet 200-325 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "23155064731", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155079041", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781347432", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288012690", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10702036199", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54879003664", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598086111", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10702036603", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155064941", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710152509", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598062857", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70121148202", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860022130", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72205019801", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860022361", "ndc_label_name": "Carmustine Solution Reconstituted 100 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729054601", "ndc_label_name": "Carmustine Solution Reconstituted 300 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729054863", "ndc_label_name": "Carmustine Solution Reconstituted 300 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729054563", "ndc_label_name": "Carmustine Solution Reconstituted 50 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729054305", "ndc_label_name": "Carmustine Solution Reconstituted 50 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54482014508", "ndc_label_name": "Carnitor Solution 1 GM/10ML Oral", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54482014701", "ndc_label_name": "Carnitor Solution 200 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314023810", "ndc_label_name": "Carteolol HCl SOLUTION 1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314023805", "ndc_label_name": "Carteolol HCl SOLUTION 1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314023815", "ndc_label_name": "Carteolol HCl SOLUTION 1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208036715", "ndc_label_name": "Carteolol HCl SOLUTION 1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208036705", "ndc_label_name": "Carteolol HCl SOLUTION 1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24208036710", "ndc_label_name": "Carteolol HCl SOLUTION 1 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090305100", "ndc_label_name": "Cartia XT Capsule Extended Release 24 Hour 120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090305101", "ndc_label_name": "Cartia XT Capsule Extended Release 24 Hour 120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62037059790", "ndc_label_name": "Cartia XT CAPSULE EXTENDED RELEASE 24 HOUR 120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62037059705", "ndc_label_name": "Cartia XT CAPSULE EXTENDED RELEASE 24 HOUR 120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090312400", "ndc_label_name": "Cartia XT Capsule Extended Release 24 Hour 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62037059805", "ndc_label_name": "Cartia XT CAPSULE EXTENDED RELEASE 24 HOUR 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62037059890", "ndc_label_name": "Cartia XT CAPSULE EXTENDED RELEASE 24 HOUR 180 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62037059905", "ndc_label_name": "Cartia XT CAPSULE EXTENDED RELEASE 24 HOUR 240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62037059990", "ndc_label_name": "Cartia XT CAPSULE EXTENDED RELEASE 24 HOUR 240 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62037060005", "ndc_label_name": "Cartia XT CAPSULE EXTENDED RELEASE 24 HOUR 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62037060090", "ndc_label_name": "Cartia XT CAPSULE EXTENDED RELEASE 24 HOUR 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664066383", "ndc_label_name": "Carvedilol Phosphate ER CAPSULE EXTENDED RELEASE 24 HOUR 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505367803", "ndc_label_name": "Carvedilol Phosphate ER Capsule Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407005030", "ndc_label_name": "Carvedilol Phosphate ER Capsule Extended Release 24 Hour 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664066483", "ndc_label_name": "Carvedilol Phosphate ER CAPSULE EXTENDED RELEASE 24 HOUR 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407005130", "ndc_label_name": "Carvedilol Phosphate ER Capsule Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505367903", "ndc_label_name": "Carvedilol Phosphate ER Capsule Extended Release 24 Hour 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664066583", "ndc_label_name": "Carvedilol Phosphate ER CAPSULE EXTENDED RELEASE 24 HOUR 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407005230", "ndc_label_name": "Carvedilol Phosphate ER Capsule Extended Release 24 Hour 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505368003", "ndc_label_name": "Carvedilol Phosphate ER CAPSULE EXTENDED RELEASE 24 HOUR 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505368103", "ndc_label_name": "Carvedilol Phosphate ER Capsule Extended Release 24 Hour 80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407005330", "ndc_label_name": "Carvedilol Phosphate ER Capsule Extended Release 24 Hour 80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664066683", "ndc_label_name": "Carvedilol Phosphate ER CAPSULE EXTENDED RELEASE 24 HOUR 80 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093729505", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544019030", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097530", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378363305", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135063505", "ndc_label_name": "Carvedilol TABLET 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378363301", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135063501", "ndc_label_name": "Carvedilol TABLET 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093729501", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904630261", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090255503", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353016070", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781522301", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097590", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407004101", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107014401", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353016053", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544019081", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597602", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090255502", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544019090", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090255500", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111025401", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063012593", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353087430", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261097560", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629366901", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343002805", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107014405", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079093120", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760049460", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353016060", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353087460", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356090860", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629366902", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597601", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353016080", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629366903", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862014401", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353087480", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025610", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353016030", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084086501", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597604", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079093101", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001015100", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788973803", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025650", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090255501", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462016401", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385011250", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024518", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597603", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382009401", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090255504", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407004105", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760023460", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036802", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597600", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024588", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919072830", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343002801", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919072890", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760014460", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462016405", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111025405", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187044790", "ndc_label_name": "Carvedilol TABLET 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760014498", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006680", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024513", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862014405", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001015103", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385011201", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187044730", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084086511", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006660", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382009405", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036806", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645035159", "ndc_label_name": "Carvedilol TABLET 12.5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036804", "ndc_label_name": "Carvedilol Tablet 12.5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544019130", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093729605", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093729601", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053760", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378363401", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135063705", "ndc_label_name": "Carvedilol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904630361", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053700", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356052600", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378363405", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544019190", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053790", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781522401", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353013330", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135063701", "ndc_label_name": "Carvedilol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079093220", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063012993", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107014505", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107014501", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353083260", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356052690", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343002905", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053730", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343002901", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090211904", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356052630", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597702", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025750", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353013380", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629407001", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261053799", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597701", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407004201", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356052660", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111025505", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407004205", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090211900", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645049659", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063012960", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024713", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111025501", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063012930", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760023560", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919053390", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079093201", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681901", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353013353", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629407002", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55154567600", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353013360", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919073060", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862014501", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597700", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090211903", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353083209", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001015200", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024788", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597703", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919073090", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462016501", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024718", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760014560", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353083280", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681908", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919073030", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335027304", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187040930", "ndc_label_name": "Carvedilol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006780", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760014598", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006760", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025710", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335027303", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862014505", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385011301", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090211901", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001015203", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597704", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382009501", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187040960", "ndc_label_name": "Carvedilol TABLET 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084087601", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071085630", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462016505", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382009505", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084087611", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681906", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385011350", "ndc_label_name": "Carvedilol TABLET 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681903", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681909", "ndc_label_name": "Carvedilol Tablet 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353083780", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093005105", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353083760", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093005101", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378363101", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781522101", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261098690", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378363105", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090206600", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107014201", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090206602", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261098660", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107014205", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135063301", "ndc_label_name": "Carvedilol TABLET 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063012693", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904630061", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629406002", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079077117", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079077119", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025410", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353083753", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135063305", "ndc_label_name": "Carvedilol TABLET 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079077101", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079077120", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462016201", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024213", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919021990", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090206603", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407003901", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261098630", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407003905", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343002605", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597403", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024218", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862014205", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343002601", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382009201", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356051360", "ndc_label_name": "Carvedilol TABLET 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597400", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597401", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006253", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760014298", "ndc_label_name": "Carvedilol TABLET 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001015300", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700032260", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111025201", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353013253", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001015303", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597402", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862014201", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187094160", "ndc_label_name": "Carvedilol TABLET 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006260", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629406001", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084084311", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025450", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462016205", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111025205", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610013253", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382009205", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610013260", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090206601", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084084301", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788969103", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610013280", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024288", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385011050", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006280", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760014260", "ndc_label_name": "Carvedilol TABLET 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919021930", "ndc_label_name": "Carvedilol Tablet 3.125 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385011001", "ndc_label_name": "Carvedilol TABLET 3.125 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261084890", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904630161", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093013505", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378363205", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093013501", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00781522201", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135063405", "ndc_label_name": "Carvedilol TABLET 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378363201", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356051260", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356051218", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544018790", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063083360", "ndc_label_name": "Carvedilol TABLET 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10135063401", "ndc_label_name": "Carvedilol TABLET 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107014301", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356051230", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261084860", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025550", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353015653", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107014305", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353083880", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261084830", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079093001", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353015660", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353083860", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084085411", "ndc_label_name": "Carvedilol TABLET 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111025301", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261084800", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090106401", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261084899", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407004005", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353083830", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025510", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382009305", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024413", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063012793", "ndc_label_name": "Carvedilol TABLET 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090217503", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356051290", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760053260", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353083853", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343002701", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335056101", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919098490", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353015680", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597501", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090217504", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462016305", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760014398", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760023360", "ndc_label_name": "Carvedilol TABLET 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335056102", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187094660", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090217500", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597502", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079093020", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681703", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629366803", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919098430", "ndc_label_name": "Carvedilol TABLET 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006353", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071084130", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090217501", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700081918", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597503", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681708", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001015400", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862014305", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385011101", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645035059", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407004001", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024418", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597504", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681709", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68001015403", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681701", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111025305", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788760301", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52343002705", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629366801", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760014360", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788760309", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68382009301", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006380", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187094690", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788760306", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569597500", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862014301", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629366802", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006360", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788760303", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084085401", "ndc_label_name": "Carvedilol TABLET 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681706", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788978903", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700081990", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788760308", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664024488", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610006330", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462016301", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76385011150", "ndc_label_name": "Carvedilol TABLET 6.25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335056104", "ndc_label_name": "Carvedilol Tablet 6.25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57894011101", "ndc_label_name": "Carvykti Suspension 100000000 CELLS Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57894011102", "ndc_label_name": "Carvykti Suspension 100000000 CELLS Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51167029001", "ndc_label_name": "Casgevy Suspension Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51167029009", "ndc_label_name": "Casgevy Suspension Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00310070530", "ndc_label_name": "Casodex Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66116021230", "ndc_label_name": "Casodex Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62559068030", "ndc_label_name": "Casodex Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597003134", "ndc_label_name": "Catapres-TTS-1 Patch Weekly 0.1 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597003234", "ndc_label_name": "Catapres-TTS-2 Patch Weekly 0.2 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959067912", "ndc_label_name": "Catapres-TTS-2 Patch Weekly 0.2 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00597003334", "ndc_label_name": "Catapres-TTS-3 Patch Weekly 0.3 MG/24HR Transdermal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50242004110", "ndc_label_name": "Cathflo Activase Solution Reconstituted 2 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50242004164", "ndc_label_name": "Cathflo Activase SOLUTION RECONSTITUTED 2 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63704002001", "ndc_label_name": "Caya DIAPHRAGM VAGINAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61958090101", "ndc_label_name": "Cayston Solution Reconstituted 75 MG Inhalation", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51862023803", "ndc_label_name": "Caziant Tablet 0.1/0.125/0.15 -0.025 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862023801", "ndc_label_name": "Caziant Tablet 0.1/0.125/0.15 -0.025 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036715", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011912", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724830", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358006520", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724806", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47781026603", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143998501", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358006530", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036730", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011915", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036714", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036740", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021130", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036700", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036721", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999019930", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011921", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011930", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569390100", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289074930", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011924", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442017130", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629130503", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036720", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629130504", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629130502", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011928", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011918", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011901", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629130501", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011920", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267026230", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629130505", "ndc_label_name": "Cefaclor Capsule 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016807", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999055742", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016821", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143998601", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358006630", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47781026703", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090051802", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016814", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016860", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442017230", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874012024", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016828", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132008", "ndc_label_name": "Cefaclor CAPSULE 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036830", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036810", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063019430", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036820", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132005", "ndc_label_name": "Cefaclor CAPSULE 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874012030", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016830", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874012001", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569390202", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036840", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999055730", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132001", "ndc_label_name": "Cefaclor CAPSULE 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874012010", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267025621", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358006620", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569390200", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874012012", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132004", "ndc_label_name": "Cefaclor CAPSULE 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036814", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132006", "ndc_label_name": "Cefaclor CAPSULE 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874012020", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132007", "ndc_label_name": "Cefaclor CAPSULE 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036828", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874012015", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959036821", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874012021", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874012018", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267025630", "ndc_label_name": "Cefaclor Capsule 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132002", "ndc_label_name": "Cefaclor CAPSULE 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132003", "ndc_label_name": "Cefaclor CAPSULE 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093108701", "ndc_label_name": "Cefaclor ER Tablet Extended Release 12 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13551025001", "ndc_label_name": "Cefaclor SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23594025001", "ndc_label_name": "Cefaclor Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571007112", "ndc_label_name": "Cefaclor SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714038802", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093319653", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093319601", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714038801", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143994720", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055320", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358006728", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055328", "ndc_label_name": "Cefadroxil CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043024250", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143994701", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143994750", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063059520", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724202", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629135802", "ndc_label_name": "Cefadroxil CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043024201", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999002110", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999002120", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724206", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358006714", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959042818", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544013520", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053312", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959042820", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569439101", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002022920", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724210", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959042814", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289058928", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001820", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053320", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959042830", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629135803", "ndc_label_name": "Cefadroxil CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569439100", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261001814", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959042815", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053304", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055314", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053372", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569439102", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629135805", "ndc_label_name": "Cefadroxil CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289058910", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063055310", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569439104", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053330", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090191502", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053377", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629135807", "ndc_label_name": "Cefadroxil CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629135808", "ndc_label_name": "Cefadroxil CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629135801", "ndc_label_name": "Cefadroxil CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063059528", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289058914", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004520", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053314", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004514", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629135809", "ndc_label_name": "Cefadroxil CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629422301", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629135804", "ndc_label_name": "Cefadroxil CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999002114", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237009650", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004530", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053315", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788641602", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053310", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053328", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629135806", "ndc_label_name": "Cefadroxil CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090191500", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053340", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788641604", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180018001", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005694", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053360", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862008501", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629422501", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959042804", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053374", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004524", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934008194", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959042810", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788641601", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959042816", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053390", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959042828", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004510", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002022914", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934008191", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289058920", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237009601", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629422401", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053301", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053325", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874053344", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862008550", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004528", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180018008", "ndc_label_name": "Cefadroxil CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788641603", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788641606", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934005691", "ndc_label_name": "Cefadroxil Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862008301", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714038901", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237009701", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143976750", "ndc_label_name": "Cefadroxil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180018102", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143976701", "ndc_label_name": "Cefadroxil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180018202", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 500 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039001", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 500 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143976601", "ndc_label_name": "Cefadroxil Suspension Reconstituted 500 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237009801", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 500 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039002", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 500 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862008401", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 500 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237009875", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 500 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143976675", "ndc_label_name": "Cefadroxil Suspension Reconstituted 500 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862008475", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 500 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180018203", "ndc_label_name": "Cefadroxil SUSPENSION RECONSTITUTED 500 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143994850", "ndc_label_name": "Cefadroxil Tablet 1 GM Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093405953", "ndc_label_name": "Cefadroxil Tablet 1 GM Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409258501", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409258511", "ndc_label_name": "CeFAZolin Sodium Solution Reconstituted 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323023861", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 10 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781345246", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 10 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143998391", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 10 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781345295", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 10 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143926101", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 10 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572005601", "ndc_label_name": "ceFAZolin Sodium Solution Reconstituted 10 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143998303", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 10 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143926110", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 10 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010269", "ndc_label_name": "ceFAZolin Sodium Solution Reconstituted 10 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567070810", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 10 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505624400", "ndc_label_name": "ceFAZolin Sodium Solution Reconstituted 10 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572005610", "ndc_label_name": "ceFAZolin Sodium Solution Reconstituted 10 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010299", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 10 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614300", "ndc_label_name": "CeFAZolin Sodium Solution Reconstituted 10 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614304", "ndc_label_name": "CeFAZolin Sodium Solution Reconstituted 10 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505624404", "ndc_label_name": "ceFAZolin Sodium Solution Reconstituted 10 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143992390", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010066", "ndc_label_name": "CeFAZolin Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781345070", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567070625", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323023610", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781345095", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010010", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68330001425", "ndc_label_name": "CeFAZolin Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00338350341", "ndc_label_name": "CeFAZolin Sodium-Dextrose Solution 1-4 GM/50ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00338350841", "ndc_label_name": "CeFAZolin Sodium-Dextrose SOLUTION 2-4 GM/100ML-% Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00264310311", "ndc_label_name": "CeFAZolin Sodium-Dextrose Solution Reconstituted 1-4 GM-%(50ML) Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00264310511", "ndc_label_name": "CeFAZolin Sodium-Dextrose Solution Reconstituted 2-3 GM-%(50ML) Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063096414", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093316006", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781217660", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090271903", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356003820", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039102", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039101", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063046614", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090271901", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090103200", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063046620", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959013420", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090103102", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043025006", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063085220", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063059720", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217003020", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569592102", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090103101", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569592101", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217003010", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063085320", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090271902", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063096420", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569592103", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700021420", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700052520", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700017120", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217003060", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063095920", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569830900", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090103103", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289008120", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237009960", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700076420", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629367101", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919084020", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090263600", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629367103", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217003030", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629367102", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788737502", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180071160", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001036206", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187098920", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919084014", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205022420", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629367105", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001015006", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934016420", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629367104", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788976002", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205022414", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862017760", "ndc_label_name": "Cefdinir CAPSULE 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67253001106", "ndc_label_name": "Cefdinir CAPSULE 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788760602", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788711102", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004420", "ndc_label_name": "Cefdinir CAPSULE 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788733902", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934006220", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68820006306", "ndc_label_name": "Cefdinir Capsule 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781607761", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781607746", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862021860", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093413664", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093413673", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039201", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187083500", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039202", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217029801", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043025167", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217007101", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356011960", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180072210", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261092601", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180072220", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72189004232", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862021801", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043025138", "ndc_label_name": "Cefdinir Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093413773", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781607846", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043025238", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781607861", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180072310", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039302", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093413764", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862021901", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788684001", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090102700", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356019000", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039301", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788725501", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187061600", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180072320", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090102800", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261090501", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862021960", "ndc_label_name": "Cefdinir SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043025267", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205038060", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090273500", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72189004332", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569591800", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788706201", "ndc_label_name": "Cefdinir Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00338130141", "ndc_label_name": "Cefepime HCl SOLUTION 1 GM/50ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00338130148", "ndc_label_name": "Cefepime HCl SOLUTION 2 GM/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794020902", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567024010", "ndc_label_name": "Cefepime HCl SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409956601", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021012166", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409956610", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614600", "ndc_label_name": "Cefepime HCl SOLUTION RECONSTITUTED 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781322295", "ndc_label_name": "Cefepime HCl SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021012120", "ndc_label_name": "Cefepime HCl SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781322280", "ndc_label_name": "Cefepime HCl SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505624500", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567013010", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614404", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614400", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008902", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323032621", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614604", "ndc_label_name": "Cefepime HCl SOLUTION RECONSTITUTED 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794020941", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288000815", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594008901", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505624504", "ndc_label_name": "Cefepime HCl Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323032620", "ndc_label_name": "Cefepime HCl SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288000920", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781322391", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781322395", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021012250", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505624600", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409973501", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594009002", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323034020", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409973510", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567013110", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614504", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567024110", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614700", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021012267", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614704", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794021002", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505624604", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614500", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323034021", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594009001", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794021041", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71288000920", "ndc_label_name": "Cefepime HCl Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00264319311", "ndc_label_name": "Cefepime-Dextrose Solution Reconstituted 1-5 GM-%(50ML) Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00264319511", "ndc_label_name": "Cefepime-Dextrose Solution Reconstituted 2-5 GM-%(50ML) Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180041608", "ndc_label_name": "Cefixime Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877058450", "ndc_label_name": "Cefixime Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180041611", "ndc_label_name": "Cefixime Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862075150", "ndc_label_name": "Cefixime SUSPENSION RECONSTITUTED 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040501", "ndc_label_name": "Cefixime Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714076601", "ndc_label_name": "Cefixime Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598067350", "ndc_label_name": "Cefixime SUSPENSION RECONSTITUTED 100 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598067450", "ndc_label_name": "Cefixime SUSPENSION RECONSTITUTED 200 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862075275", "ndc_label_name": "Cefixime SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714076701", "ndc_label_name": "Cefixime Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714076702", "ndc_label_name": "Cefixime Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598067451", "ndc_label_name": "Cefixime SUSPENSION RECONSTITUTED 200 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040703", "ndc_label_name": "Cefixime Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862075250", "ndc_label_name": "Cefixime SUSPENSION RECONSTITUTED 200 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040704", "ndc_label_name": "Cefixime Suspension Reconstituted 200 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "21586011002", "ndc_label_name": "Cefotaxime Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143987825", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323034129", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567024525", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010910", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323034125", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143987801", "ndc_label_name": "CefOXitin Sodium Solution Reconstituted 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567024585", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323034101", "ndc_label_name": "CefOXitin Sodium Solution Reconstituted 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505076104", "ndc_label_name": "cefOXitin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505076101", "ndc_label_name": "cefOXitin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143987610", "ndc_label_name": "cefOXitin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567024710", "ndc_label_name": "cefOXitin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021011199", "ndc_label_name": "cefOXitin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323034366", "ndc_label_name": "cefOXitin Sodium Solution Reconstituted 10 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021011020", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567024685", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143987725", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323034225", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143987701", "ndc_label_name": "CefOXitin Sodium Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567024625", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323034229", "ndc_label_name": "CefOXitin Sodium SOLUTION RECONSTITUTED 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323034201", "ndc_label_name": "CefOXitin Sodium Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00264312311", "ndc_label_name": "CefOXitin Sodium-Dextrose Solution Reconstituted 1-4 GM-%(50ML) Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00264312511", "ndc_label_name": "CefOXitin Sodium-Dextrose Solution Reconstituted 2-2.2 GM-%(50ML) Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980040350", "ndc_label_name": "Cefpodoxime Proxetil Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980040310", "ndc_label_name": "Cefpodoxime Proxetil Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714040302", "ndc_label_name": "Cefpodoxime Proxetil SUSPENSION RECONSTITUTED 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781616946", "ndc_label_name": "Cefpodoxime Proxetil Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781616952", "ndc_label_name": "Cefpodoxime Proxetil Suspension Reconstituted 100 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714040301", "ndc_label_name": "Cefpodoxime Proxetil SUSPENSION RECONSTITUTED 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862014101", "ndc_label_name": "Cefpodoxime Proxetil SUSPENSION RECONSTITUTED 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862014150", "ndc_label_name": "Cefpodoxime Proxetil SUSPENSION RECONSTITUTED 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862014050", "ndc_label_name": "Cefpodoxime Proxetil SUSPENSION RECONSTITUTED 50 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781616852", "ndc_label_name": "Cefpodoxime Proxetil Suspension Reconstituted 50 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781616846", "ndc_label_name": "Cefpodoxime Proxetil Suspension Reconstituted 50 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714040201", "ndc_label_name": "Cefpodoxime Proxetil SUSPENSION RECONSTITUTED 50 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714040202", "ndc_label_name": "Cefpodoxime Proxetil SUSPENSION RECONSTITUTED 50 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862014001", "ndc_label_name": "Cefpodoxime Proxetil SUSPENSION RECONSTITUTED 50 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781543820", "ndc_label_name": "Cefpodoxime Proxetil TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043012020", "ndc_label_name": "Cefpodoxime Proxetil Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959079610", "ndc_label_name": "Cefpodoxime Proxetil Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862009501", "ndc_label_name": "Cefpodoxime Proxetil TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039401", "ndc_label_name": "Cefpodoxime Proxetil TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862009520", "ndc_label_name": "Cefpodoxime Proxetil TABLET 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043012120", "ndc_label_name": "Cefpodoxime Proxetil Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358006820", "ndc_label_name": "Cefpodoxime Proxetil Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781543920", "ndc_label_name": "Cefpodoxime Proxetil TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781543901", "ndc_label_name": "Cefpodoxime Proxetil TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289039302", "ndc_label_name": "Cefpodoxime Proxetil TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862009601", "ndc_label_name": "Cefpodoxime Proxetil TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039501", "ndc_label_name": "Cefpodoxime Proxetil TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862009620", "ndc_label_name": "Cefpodoxime Proxetil TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781620291", "ndc_label_name": "Cefprozil Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781620246", "ndc_label_name": "Cefprozil Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003475", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003450", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043026238", "ndc_label_name": "Cefprozil Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781620257", "ndc_label_name": "Cefprozil Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304096001", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039602", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039601", "ndc_label_name": "Cefprozil Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862009901", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040101", "ndc_label_name": "Cefprozil Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040102", "ndc_label_name": "Cefprozil Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043026257", "ndc_label_name": "Cefprozil Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862009975", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039603", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003401", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043026277", "ndc_label_name": "Cefprozil Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040103", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304096003", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039701", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043026338", "ndc_label_name": "Cefprozil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039702", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043026377", "ndc_label_name": "Cefprozil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781620357", "ndc_label_name": "Cefprozil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781620346", "ndc_label_name": "Cefprozil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862010075", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043026357", "ndc_label_name": "Cefprozil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569578500", "ndc_label_name": "Cefprozil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090322600", "ndc_label_name": "Cefprozil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040202", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003501", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039703", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781620391", "ndc_label_name": "Cefprozil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003575", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304096101", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040203", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003550", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862010001", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569675600", "ndc_label_name": "Cefprozil Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040201", "ndc_label_name": "Cefprozil SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724703", "ndc_label_name": "Cefprozil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304014801", "ndc_label_name": "Cefprozil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039801", "ndc_label_name": "Cefprozil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093107701", "ndc_label_name": "Cefprozil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862006801", "ndc_label_name": "Cefprozil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781504301", "ndc_label_name": "Cefprozil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724720", "ndc_label_name": "Cefprozil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003601", "ndc_label_name": "Cefprozil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040301", "ndc_label_name": "Cefprozil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781504450", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724620", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217003120", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090173900", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714039901", "ndc_label_name": "Cefprozil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862006901", "ndc_label_name": "Cefprozil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237003750", "ndc_label_name": "Cefprozil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093107853", "ndc_label_name": "Cefprozil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217003130", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781504401", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700045520", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862006950", "ndc_label_name": "Cefprozil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063084220", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700029420", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304014901", "ndc_label_name": "Cefprozil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569619500", "ndc_label_name": "Cefprozil TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959030020", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180040401", "ndc_label_name": "Cefprozil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700070820", "ndc_label_name": "Cefprozil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304014950", "ndc_label_name": "Cefprozil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00264314311", "ndc_label_name": "cefTAZidime and Dextrose Solution Reconstituted 1-5 GM-%(50ML) Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00264314511", "ndc_label_name": "cefTAZidime and Dextrose Solution Reconstituted 2-5 GM-%(50ML) Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021012720", "ndc_label_name": "CefTAZidime SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567023525", "ndc_label_name": "CefTAZidime SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021012766", "ndc_label_name": "CefTAZidime Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021012867", "ndc_label_name": "cefTAZidime Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021012850", "ndc_label_name": "cefTAZidime Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567023610", "ndc_label_name": "cefTAZidime Solution Reconstituted 2 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021012969", "ndc_label_name": "CefTAZidime Solution Reconstituted 6 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021012999", "ndc_label_name": "CefTAZidime SOLUTION RECONSTITUTED 6 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567023706", "ndc_label_name": "CefTAZidime SOLUTION RECONSTITUTED 6 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00338500241", "ndc_label_name": "CefTRIAXone Sodium in Dextrose SOLUTION 20 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00338500341", "ndc_label_name": "CefTRIAXone Sodium in Dextrose SOLUTION 40 MG/ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733201", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679098301", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733221", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985725", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985701", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733211", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567070125", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781320885", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781320895", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794021302", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614804", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010610", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733220", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180063310", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567070195", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010667", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090094500", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68330000301", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518309900", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090094501", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614800", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518016800", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68330000310", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794021342", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323034610", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518249900", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205054501", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090271200", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679098302", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 1 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180063301", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572006125", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090381000", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518249901", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090381001", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594009602", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518309901", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518335500", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518335501", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572006101", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 1 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985601", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733521", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010720", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733503", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985625", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733513", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68330000401", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567070225", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614904", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794021402", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68330000410", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781320995", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733520", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010768", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594009702", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679070301", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794021442", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180064410", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781320990", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572006201", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180064401", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567070295", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72572006225", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505614900", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679070302", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 2 GM INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985901", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985925", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781320685", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090244400", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679070101", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733721", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090187500", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505615101", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733701", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733720", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679070103", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68330000101", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205011701", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68330000110", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794021102", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781320695", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733711", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594009402", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180061101", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505615104", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679070102", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 250 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794021142", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180061110", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 250 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733821", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781320785", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010566", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733820", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733801", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505615204", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567070025", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985801", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021010510", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781320795", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794021202", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180062210", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090262800", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679070201", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090344700", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143985825", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518230101", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794021242", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68330000201", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409733811", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090383800", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090094400", "ndc_label_name": "CefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518230100", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505615201", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70594009502", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679070202", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180062201", "ndc_label_name": "cefTRIAXone Sodium Solution Reconstituted 500 MG Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68330000210", "ndc_label_name": "CefTRIAXone Sodium SOLUTION RECONSTITUTED 500 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00264315311", "ndc_label_name": "CefTRIAXone Sodium-Dextrose Solution Reconstituted 1-3.74 GM-%(50ML) Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00264315511", "ndc_label_name": "CefTRIAXone Sodium-Dextrose Solution Reconstituted 2-2.22 GM-%(50ML) Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714040002", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999030930", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724503", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090215900", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724504", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261043820", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714040001", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090215803", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261043830", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090215800", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063058420", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919074720", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043023006", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261043860", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237005820", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52343006220", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569538600", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569538602", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063065760", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180030260", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063026904", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043023020", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132103", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569830800", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132102", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237005860", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569538603", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289038530", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063065720", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52343006260", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679092102", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919014520", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679092101", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429065660", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429065620", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187099120", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999030920", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002027520", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862069920", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132101", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877021560", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687027211", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687027294", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289038504", "ndc_label_name": "Cefuroxime Axetil Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862069960", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919004420", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180030220", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877021520", "ndc_label_name": "Cefuroxime Axetil TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52343006320", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261061520", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090215700", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261061530", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714040101", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999078520", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714040102", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261061560", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52343006360", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862070020", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700043620", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043023120", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436502201", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959093920", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002026720", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043023106", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237005960", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877021660", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72789003520", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063030720", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959093930", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569541800", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237005920", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877021620", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629356201", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934008820", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429065720", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788991403", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629356202", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700065520", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429065760", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788991406", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180030320", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679092202", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64679092201", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862070060", "ndc_label_name": "Cefuroxime Axetil TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788991402", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180030360", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72789003560", "ndc_label_name": "Cefuroxime Axetil Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143956725", "ndc_label_name": "Cefuroxime Sodium Solution Reconstituted 1.5 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143956701", "ndc_label_name": "Cefuroxime Sodium Solution Reconstituted 1.5 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143997790", "ndc_label_name": "Cefuroxime Sodium Solution Reconstituted 1.5 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143997722", "ndc_label_name": "Cefuroxime Sodium Solution Reconstituted 1.5 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021011920", "ndc_label_name": "Cefuroxime Sodium Solution Reconstituted 1.5 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143997922", "ndc_label_name": "Cefuroxime Sodium SOLUTION RECONSTITUTED 750 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143956825", "ndc_label_name": "Cefuroxime Sodium SOLUTION RECONSTITUTED 750 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143956801", "ndc_label_name": "Cefuroxime Sodium SOLUTION RECONSTITUTED 750 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143997990", "ndc_label_name": "Cefuroxime Sodium SOLUTION RECONSTITUTED 750 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021011810", "ndc_label_name": "Cefuroxime Sodium SOLUTION RECONSTITUTED 750 MG INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261065307", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006920", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261065310", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261065330", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025152034", "ndc_label_name": "CeleBREX CAPSULE 100 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467102", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261065321", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025152031", "ndc_label_name": "CeleBREX CAPSULE 100 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289045120", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006930", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959054030", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006960", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358006914", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864069120", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261065360", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025152051", "ndc_label_name": "CeleBREX CAPSULE 100 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330103", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959054015", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959054014", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436780101", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959054020", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330101", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051721", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959054040", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051714", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959054028", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051728", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959054021", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467101", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051712", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051760", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289045114", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051720", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959054060", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004614", "ndc_label_name": "CeleBREX CAPSULE 100 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467100", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467104", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051730", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051790", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051715", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051701", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289045130", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051725", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864069130", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004660", "ndc_label_name": "CeleBREX CAPSULE 100 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004630", "ndc_label_name": "CeleBREX CAPSULE 100 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629330102", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051710", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874051724", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66116011730", "ndc_label_name": "CeleBREX Capsule 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004620", "ndc_label_name": "CeleBREX CAPSULE 100 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440724030", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025152531", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025152551", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001921", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007090", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001900", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001902", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025152534", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001910", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001928", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "12634083471", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007014", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053900", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007015", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001915", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001990", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001920", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053914", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001907", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007030", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053910", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49848000700", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001960", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007060", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007010", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053940", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261001930", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436760201", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053915", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053920", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053907", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053930", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007020", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053990", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053905", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053928", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289047528", "ndc_label_name": "CeleBREX CAPSULE 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053921", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289047520", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053945", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436760202", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467204", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467200", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467209", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919004630", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289047590", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289047593", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053950", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289047510", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467205", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467201", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289047560", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049521", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864070930", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760052560", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959053960", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760052530", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629302106", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467206", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760052520", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049530", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629302104", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629302103", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569467202", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629302101", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629302109", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289047514", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629302102", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004710", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629302107", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049512", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289047530", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629302108", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004810", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629302110", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629302105", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049514", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049507", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049528", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919004660", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105010603", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004815", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049501", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66116011830", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004860", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049510", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049515", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049505", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049560", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049590", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544020430", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004807", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874049520", "ndc_label_name": "CeleBREX Capsule 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004856", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004715", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004820", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267004830", "ndc_label_name": "CeleBREX CAPSULE 200 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025153001", "ndc_label_name": "CeleBREX Capsule 400 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025153002", "ndc_label_name": "CeleBREX Capsule 400 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959090430", "ndc_label_name": "CeleBREX Capsule 400 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00025151501", "ndc_label_name": "CeleBREX Capsule 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093716501", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093716505", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668044101", "ndc_label_name": "Celecoxib CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904650261", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378716001", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811065910", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378406601", "ndc_label_name": "Celecoxib CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342015615", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378716005", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591398301", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342015611", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291019350", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591282005", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055914", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714073201", "ndc_label_name": "Celecoxib CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700042960", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591282001", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291019390", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268016815", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571014305", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668044105", "ndc_label_name": "Celecoxib CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055920", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571014301", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700061360", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591398305", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687043601", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079019901", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436398301", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268016811", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079019920", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015630", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687043611", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714073202", "ndc_label_name": "Celecoxib CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919004530", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700019630", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760082360", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429046001", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762151603", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015660", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919004360", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436790101", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187033160", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700044960", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919068230", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919004560", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429046005", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700019660", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180039601", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700042930", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084096911", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919004330", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332014131", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629550401", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505384805", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700061330", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180039602", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700044930", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788728606", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187030160", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629550402", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862090801", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788728609", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505384801", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69399018381", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762151601", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097042207", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187064360", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629550403", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788694103", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788892406", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332014171", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71626030201", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760020960", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097042212", "ndc_label_name": "Celecoxib CAPSULE 100 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084096901", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205002060", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788694106", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335029203", "ndc_label_name": "Celecoxib CAPSULE 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629550404", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335029201", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788728603", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71626030205", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788892409", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71626030230", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788694109", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788892403", "ndc_label_name": "Celecoxib Capsule 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904650361", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591398401", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378715005", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358090230", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342015711", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378715001", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093716601", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093716605", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668044201", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811066010", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591282501", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055514", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358090215", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811066050", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591398405", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668044205", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714073301", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571014405", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544095314", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055530", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291019490", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342015715", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063066960", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714073302", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571014401", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063066910", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055510", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063066930", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055520", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291019450", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063082510", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063066010", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063066914", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353025753", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063055560", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436398401", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063066920", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090242701", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063082530", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063082514", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063096730", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090318301", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090242700", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015730", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063096760", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436384902", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063082560", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353003630", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268016915", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090318302", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268016911", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700045014", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079021520", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217020630", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353025730", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700033760", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079021501", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436384901", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436398402", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919036015", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217031160", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700060730", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353025760", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700043014", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217015760", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436770101", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217031130", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332014231", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700019914", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762151703", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090318300", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700043060", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217020660", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436770102", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700019930", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862090901", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762151701", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505384905", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569658002", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700060760", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569658000", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217031190", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700045030", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180039901", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919036030", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760020830", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700019960", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760082415", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700033730", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569658001", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700045060", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180039902", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919036042", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919036010", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429046105", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760084930", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700043030", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429046101", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760082430", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788713401", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919036060", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187056230", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687044701", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919083710", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60687044711", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505384901", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760082460", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788726406", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919083790", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629550301", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760084915", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919083760", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919016830", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760020815", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919016860", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788893603", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788646308", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788726403", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760084960", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332014271", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332014291", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760020860", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187056260", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69677015415", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788646309", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896901", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919083730", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084097611", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629550304", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629550302", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187063330", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205002730", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788726401", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896906", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187063360", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180039701", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788639303", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788639306", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629550303", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335106606", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896909", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788927309", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084097601", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788646301", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788639308", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788639309", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788639301", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788646306", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69399018481", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69399018485", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180039702", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788927306", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788646303", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788713408", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788713403", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205005560", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934002614", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69677015401", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896903", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335086802", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788713406", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097042107", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788726409", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610028330", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036103", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69677015430", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69677015460", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097042112", "ndc_label_name": "Celecoxib CAPSULE 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788713409", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036104", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788893606", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69399019485", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788927303", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610028353", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69677015490", "ndc_label_name": "Celecoxib CAPSULE 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70882012914", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335086801", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610028360", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788893609", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205005530", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71626030330", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71626030301", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71205002760", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71626030305", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036101", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036102", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335036107", "ndc_label_name": "Celecoxib Capsule 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591398560", "ndc_label_name": "Celecoxib CAPSULE 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093717006", "ndc_label_name": "Celecoxib Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862091060", "ndc_label_name": "Celecoxib CAPSULE 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668031005", "ndc_label_name": "Celecoxib CAPSULE 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69399018581", "ndc_label_name": "Celecoxib CAPSULE 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668031001", "ndc_label_name": "Celecoxib CAPSULE 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668031060", "ndc_label_name": "Celecoxib CAPSULE 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571014560", "ndc_label_name": "Celecoxib Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714073401", "ndc_label_name": "Celecoxib CAPSULE 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378717091", "ndc_label_name": "Celecoxib Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097042003", "ndc_label_name": "Celecoxib CAPSULE 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811066160", "ndc_label_name": "Celecoxib Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429046260", "ndc_label_name": "Celecoxib Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342015809", "ndc_label_name": "Celecoxib CAPSULE 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291019560", "ndc_label_name": "Celecoxib Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762151802", "ndc_label_name": "Celecoxib Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180039807", "ndc_label_name": "Celecoxib Capsule 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332014360", "ndc_label_name": "Celecoxib CAPSULE 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429045960", "ndc_label_name": "Celecoxib Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668030760", "ndc_label_name": "Celecoxib CAPSULE 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591398260", "ndc_label_name": "Celecoxib CAPSULE 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093730606", "ndc_label_name": "Celecoxib Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16714073101", "ndc_label_name": "Celecoxib CAPSULE 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505384706", "ndc_label_name": "Celecoxib CAPSULE 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811065860", "ndc_label_name": "Celecoxib Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42571014260", "ndc_label_name": "Celecoxib Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862090760", "ndc_label_name": "Celecoxib CAPSULE 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71626030101", "ndc_label_name": "Celecoxib Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33342015509", "ndc_label_name": "Celecoxib CAPSULE 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378716591", "ndc_label_name": "Celecoxib Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62332014060", "ndc_label_name": "Celecoxib CAPSULE 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71626030130", "ndc_label_name": "Celecoxib Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291019260", "ndc_label_name": "Celecoxib Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097042303", "ndc_label_name": "Celecoxib CAPSULE 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68180039507", "ndc_label_name": "Celecoxib CAPSULE 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69399018281", "ndc_label_name": "Celecoxib CAPSULE 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59762151501", "ndc_label_name": "Celecoxib Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71626030160", "ndc_label_name": "Celecoxib Capsule 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00085432001", "ndc_label_name": "Celestone Soluspan Suspension 6 (3-3) MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "78206011801", "ndc_label_name": "Celestone Soluspan Suspension 6 (3-3) MG/ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00456401001", "ndc_label_name": "CeleXA TABLET 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864084930", "ndc_label_name": "CeleXA Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959001000", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959001030", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060990", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289082730", "ndc_label_name": "CeleXA TABLET 20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959001060", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456402001", "ndc_label_name": "CeleXA TABLET 20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864085230", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267061830", "ndc_label_name": "CeleXA TABLET 20 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060910", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060920", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060930", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544017030", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060901", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874060960", "ndc_label_name": "CeleXA Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00456404001", "ndc_label_name": "CeleXA TABLET 40 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864061615", "ndc_label_name": "CeleXA Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544020945", "ndc_label_name": "CeleXA Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544020915", "ndc_label_name": "CeleXA Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544020960", "ndc_label_name": "CeleXA Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864061630", "ndc_label_name": "CeleXA Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544020953", "ndc_label_name": "CeleXA Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544020930", "ndc_label_name": "CeleXA Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544020973", "ndc_label_name": "CeleXA Tablet 40 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00004025943", "ndc_label_name": "CellCept CAPSULE 250 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00004025901", "ndc_label_name": "CellCept CAPSULE 250 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00004029809", "ndc_label_name": "CellCept Intravenous SOLUTION RECONSTITUTED 500 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00004026129", "ndc_label_name": "CellCept SUSPENSION RECONSTITUTED 200 MG/ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00004026001", "ndc_label_name": "CellCept TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00004026043", "ndc_label_name": "CellCept TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00071052524", "ndc_label_name": "Celontin Capsule 300 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43538031030", "ndc_label_name": "Centany AT Kit 2 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43538030030", "ndc_label_name": "Centany Ointment 2 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23359010010", "ndc_label_name": "Centratex CAPSULE 106-1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23359010030", "ndc_label_name": "Centratex CAPSULE 106-1 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00005445170", "ndc_label_name": "Centrum Adults Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005445174", "ndc_label_name": "Centrum Adults TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005490592", "ndc_label_name": "Centrum Flavor Burst Adult TABLET CHEWABLE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005490692", "ndc_label_name": "Centrum Flavor Burst Kids Tablet Chewable Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005434462", "ndc_label_name": "Centrum Liquid Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005434362", "ndc_label_name": "Centrum Liquid Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005434361", "ndc_label_name": "Centrum LIQUID† ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005443013", "ndc_label_name": "Centrum Performance TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005443061", "ndc_label_name": "Centrum Performance TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54868036700", "ndc_label_name": "Centrum Performance TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005446119", "ndc_label_name": "Centrum Silver TABLET CHEWABLE ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005417758", "ndc_label_name": "Centrum Silver TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005417723", "ndc_label_name": "Centrum Silver TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54868531800", "ndc_label_name": "Centrum Silver TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005446391", "ndc_label_name": "Centrum Silver TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005446367", "ndc_label_name": "Centrum Silver Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68115080822", "ndc_label_name": "Centrum Silver TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005417719", "ndc_label_name": "Centrum Silver Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005446381", "ndc_label_name": "Centrum Silver TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005447013", "ndc_label_name": "Centrum Specialist Energy TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005447060", "ndc_label_name": "Centrum Specialist Energy TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005423936", "ndc_label_name": "Centrum TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005423918", "ndc_label_name": "Centrum TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00005423930", "ndc_label_name": "Centrum TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49614025878", "ndc_label_name": "Century Mature TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49614025887", "ndc_label_name": "Century Mature TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49614025787", "ndc_label_name": "Century TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205084787", "ndc_label_name": "Century TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205084781", "ndc_label_name": "Century TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49614025797", "ndc_label_name": "Century TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00093314501", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440124340", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544086840", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093314505", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "12634043371", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724328", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007120", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544002130", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00463225005", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007140", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094628", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724340", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043014005", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544014230", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043014001", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094608", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007115", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001628", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007160", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544086830", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001604", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094621", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42582021110", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063049730", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42582021118", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063049708", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001630", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007128", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001610", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094630", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001615", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999004112", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001606", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063049720", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001640", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999004120", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999004128", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094640", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063049710", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090329100", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001609", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063049740", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063049728", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007002", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090320204", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291020850", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090320205", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003056", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001624", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999004104", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090320202", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007203", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003020", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063001620", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090320208", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030403", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063049704", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007100", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003008", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268015111", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569831500", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999004110", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268015115", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005710", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063049706", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007204", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217029940", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030408", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868015302", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999004130", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003001", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005715", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063049709", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003024", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030402", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005706", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005720", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007300", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003040", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005730", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063049715", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569502403", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030405", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005728", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864007240", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090320203", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005724", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864007230", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007202", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700014540", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700014530", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011112", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756029313", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003012", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005740", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687015201", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007205", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700062040", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700062030", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011120", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756029388", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003030", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011172", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62584023501", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007208", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131701", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442016101", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011121", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011101", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348056028", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011177", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131705", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003028", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131702", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011114", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011180", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116012140", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868015306", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116068540", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629425701", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030404", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011128", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011115", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64205010114", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543010150", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687015211", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004912", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629426701", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700062028", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011140", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001840", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004920", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76439010110", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442016105", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788899403", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011104", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131703", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011150", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76439010150", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877022005", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131704", "ndc_label_name": "Cephalexin CAPSULE 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919005030", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788899404", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011116", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629422201", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001801", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934010840", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003794", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011130", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629426801", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011156", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011124", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011160", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116068428", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004930", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001805", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004940", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011174", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180012101", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267004928", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180012102", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788899402", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788899406", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877022001", "ndc_label_name": "Cephalexin CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934008294", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116012128", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543010110", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788899407", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003730", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267076904", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934008230", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788899408", "ndc_label_name": "Cephalexin Capsule 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093314705", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724440", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440124440", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544002010", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544002514", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143989701", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093314701", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544000414", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143989705", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544000420", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544001340", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544005720", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544002530", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00463250005", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544008240", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544000428", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440724430", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544000430", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544008220", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002040", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544005740", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544002540", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544061714", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544001328", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544008228", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544005721", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544061720", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002042", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544008210", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544005714", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094510", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544002510", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544052940", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544005730", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007228", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007221", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544008230", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544005728", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "12634043440", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544002528", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544061740", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544005760", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356097865", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007230", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544050330", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544050314", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "12634043480", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094512", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094530", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544008214", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004708", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356097820", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544061728", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544050340", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002002", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094528", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002030", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544008221", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004709", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004728", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544061730", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094560", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002008", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094540", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007220", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544050320", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004756", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053608", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094514", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "12634043471", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002060", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002020", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356097875", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094520", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063036220", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053609", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002007", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002048", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007214", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356097830", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004706", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094521", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053604", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999000721", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002010", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356097828", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004704", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42582021218", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004710", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002014", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053614", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999000760", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002090", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356097840", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004730", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063036230", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004724", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002021", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053628", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090274900", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007240", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043014105", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090305200", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063036240", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063036221", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261002028", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090311101", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090305700", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291020950", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053610", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268015211", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999000712", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063036228", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007215", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090319900", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090305703", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004720", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053630", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436221001", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090305707", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053640", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007260", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090319901", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090305706", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004740", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053656", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003100", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090342703", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999000790", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356097810", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090319906", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090319902", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053621", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999000715", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003106", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436102001", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007900", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043014101", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436011705", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436011701", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999000710", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007906", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003120", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436221002", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090007901", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42582021210", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436102004", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436011708", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090267700", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090008100", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348055540", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436221004", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090305702", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004714", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003102", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003110", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090274901", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090305701", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030508", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003121", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090305705", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063004721", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003115", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003112", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090325200", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090305708", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700004340", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348055520", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090319903", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053606", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021810", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021814", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436011702", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090319905", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053320", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030501", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003114", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053620", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021820", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217020710", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436011703", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090342701", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053330", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030507", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021830", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999000700", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021821", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030503", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436102005", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217020730", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118029402", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569332401", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348055514", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268015215", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021840", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569906001", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51655072051", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217020740", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118029407", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569832300", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54348055528", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436011704", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217020720", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005804", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003140", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030500", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687016311", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005830", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569906000", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436102002", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005821", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005840", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003156", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030502", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919005120", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700004320", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005808", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436221005", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005828", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919002910", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700000920", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030505", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919005130", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118029403", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005820", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003104", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700000914", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919003514", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700004314", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569332403", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919052228", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118029404", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700036430", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003108", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700036420", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919003528", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919060614", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005814", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187004614", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919002928", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700036440", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003124", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053314", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756029488", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919060656", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005824", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187059206", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919002930", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442016201", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003128", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864007328", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187004640", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187045428", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700000940", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187059228", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919035828", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919003530", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003130", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864007356", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187059240", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187059220", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053310", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131904", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62250080208", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919052240", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003160", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919002940", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629422101", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629422001", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053328", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131905", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187004606", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62584023601", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002021828", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919003510", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629426901", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011216", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053340", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629427001", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131903", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187059230", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569030506", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919003540", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011208", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011230", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687016301", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629762901", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011210", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131900", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289005856", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919041010", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011256", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011260", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442016205", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011201", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011215", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131901", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700004328", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919060620", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011274", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011277", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919003520", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011214", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011221", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131906", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864007320", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919060630", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877021984", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64205010214", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919052210", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011225", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011224", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629425901", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864007330", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919060640", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180012202", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116012328", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919052220", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011228", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001940", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011272", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864007340", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187004630", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788995003", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005040", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919052230", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011240", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005012", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005028", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919002920", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131908", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543010210", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788975204", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756029413", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011250", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005014", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005060", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919041030", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131909", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69543010250", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004010", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187045430", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001901", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071435502", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267077004", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919060628", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011204", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003420", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180012201", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187045440", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005005", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071435507", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788995007", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187004615", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64205010240", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003440", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003421", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131902", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005006", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788932602", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003430", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187004628", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862001905", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003494", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004040", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629131907", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005030", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788932604", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005020", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629423001", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877021905", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004030", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788995002", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629421901", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788975207", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788975202", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788995004", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011203", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003414", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934010928", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934010910", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011220", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788975203", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011205", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004020", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116025528", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004021", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011206", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934006594", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116025540", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011212", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005010", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874011218", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005015", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116068628", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267077006", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116068740", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071202408", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267055928", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934003428", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877021901", "ndc_label_name": "Cephalexin CAPSULE 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004056", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76439010250", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004094", "ndc_label_name": "Cephalexin Capsule 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76439010210", "ndc_label_name": "Cephalexin CAPSULE 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "48102002120", "ndc_label_name": "Cephalexin Capsule 750 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877025520", "ndc_label_name": "Cephalexin Capsule 750 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "48102002150", "ndc_label_name": "Cephalexin Capsule 750 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877025523", "ndc_label_name": "Cephalexin Capsule 750 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24979015438", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442020101", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093417573", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959020001", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180012301", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093417574", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959020002", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24979015414", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999071300", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 125 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877054488", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261074401", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180044001", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569102300", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877054468", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180044002", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043014238", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043014258", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788739102", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788739101", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180012302", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442020102", "ndc_label_name": "Cephalexin Suspension Reconstituted 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043014358", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093417773", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048501", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24979015514", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24979015538", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261048901", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42043014338", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090022000", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569102400", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093417774", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999026100", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788727102", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569102500", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442020201", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959062001", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959062000", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788898601", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700014900", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999026120", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788898602", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700065600", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180012401", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118997302", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919079832", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442020202", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700056300", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090021900", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116060720", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877054568", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180044101", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700084100", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267098200", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877054588", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267098120", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919004932", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 250 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788727101", "ndc_label_name": "Cephalexin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180044102", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68180012402", "ndc_label_name": "Cephalexin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093223801", "ndc_label_name": "Cephalexin Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093224001", "ndc_label_name": "Cephalexin Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335050696", "ndc_label_name": "Cequa Solution 0.09 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73108000001", "ndc_label_name": "CeQur Simplicity 2U Device", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73108000008", "ndc_label_name": "CeQur Simplicity 2U Device", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73108000100", "ndc_label_name": "CeQur Simplicity Inserter", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00851050031", "ndc_label_name": "CeraLyte 70 SOLUTION ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00851050030", "ndc_label_name": "CeraLyte 70 SOLUTION Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00851050033", "ndc_label_name": "CeraLyte 70 SOLUTION Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00851050014", "ndc_label_name": "CeraSport EX1 SOLUTION ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00851050013", "ndc_label_name": "CeraSport EX1 SOLUTION ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00851050012", "ndc_label_name": "CeraSport SOLUTION ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00851050055", "ndc_label_name": "CeraSport SOLUTION ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00851059027", "ndc_label_name": "CeraSport SOLUTION ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "58468022001", "ndc_label_name": "Cerdelga CAPSULE 84 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58468466301", "ndc_label_name": "Cerezyme SOLUTION RECONSTITUTED 400 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00536344308", "ndc_label_name": "Cerovite Jr Tablet Chewable 18 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00536344508", "ndc_label_name": "Cerovite Senior TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37864000043", "ndc_label_name": "Certa Plus Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51645073801", "ndc_label_name": "Certa Plus TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "17856502301", "ndc_label_name": "Certa-Vite Liquid Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904548652", "ndc_label_name": "CertaVite Senior/Antioxidant TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904548689", "ndc_label_name": "CertaVite Senior/Antioxidant Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904264146", "ndc_label_name": "CertaVite/Antioxidants Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904264113", "ndc_label_name": "CertaVite/Antioxidants TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904264180", "ndc_label_name": "CertaVite/Antioxidants TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904264172", "ndc_label_name": "CertaVite/Antioxidants TABLET ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "67544074665", "ndc_label_name": "CertaVite/Antioxidants Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904676520", "ndc_label_name": "Cetirizine HCl Allergy Child Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54838055240", "ndc_label_name": "Cetirizine HCl Allergy Child Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51672210208", "ndc_label_name": "Cetirizine HCl Allergy Child SOLUTION 5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68788899201", "ndc_label_name": "Cetirizine HCl Allergy Child Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672208808", "ndc_label_name": "Cetirizine HCl Childrens Alrgy Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45802097426", "ndc_label_name": "Cetirizine HCl Childrens Alrgy Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68094072059", "ndc_label_name": "Cetirizine HCl Childrens SOLUTION 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68094072062", "ndc_label_name": "Cetirizine HCl Childrens SOLUTION 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68094000459", "ndc_label_name": "Cetirizine HCl Childrens SOLUTION 5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68094000462", "ndc_label_name": "Cetirizine HCl Childrens SOLUTION 5 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "23155029251", "ndc_label_name": "Cetirizine HCl Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13668059607", "ndc_label_name": "Cetirizine HCl Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51991083716", "ndc_label_name": "Cetirizine HCl Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672407008", "ndc_label_name": "Cetirizine HCl SOLUTION 1 MG/ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090208400", "ndc_label_name": "Cetirizine HCl Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802062626", "ndc_label_name": "Cetirizine HCl Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569606800", "ndc_label_name": "Cetirizine HCl Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "51991083704", "ndc_label_name": "Cetirizine HCl Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090265900", "ndc_label_name": "Cetirizine HCl Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54838057280", "ndc_label_name": "Cetirizine HCl Solution 1 MG/ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788847001", "ndc_label_name": "Cetirizine HCl Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121087416", "ndc_label_name": "Cetirizine HCl Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118997201", "ndc_label_name": "Cetirizine HCl Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00121087404", "ndc_label_name": "Cetirizine HCl Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571013412", "ndc_label_name": "Cetirizine HCl Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13668002907", "ndc_label_name": "Cetirizine HCl Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378363705", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536408888", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00440725530", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00440725585", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00378363701", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536104105", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904671740", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536408811", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00536408807", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904671761", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00440725581", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "12634098771", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00440725590", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00781168401", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904671743", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904671746", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16714079902", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "43353021760", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904585261", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16714027103", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904671741", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904671772", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904671786", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16714079901", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16714079903", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "43598081112", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "33261039320", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "33261039390", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904671760", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16571040210", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16571040250", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "33261039314", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090318802", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "58118700209", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090108900", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "43353026260", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16714027102", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "33261039330", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16714079904", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "35356086430", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660093930", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60687016501", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090318803", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "43598081115", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "43292056294", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "45802091939", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "33261039300", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090108903", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54569604200", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61919053890", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660093890", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090108902", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "43353021730", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "45802091987", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "33261039310", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090318801", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54569604202", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68071074630", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "52959092307", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55154667504", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "43353026230", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51079059701", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090318800", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660093831", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60505263308", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71205020710", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "52959092330", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55289099507", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090108901", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660093854", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51079059720", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660093901", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68788690505", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71335030002", "ndc_label_name": "Cetirizine HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55154667507", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60687016511", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71205016430", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660093954", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660093830", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "52959092315", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68788690506", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51660093990", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60760004430", "ndc_label_name": "Cetirizine HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "63187093230", "ndc_label_name": "Cetirizine HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71205020706", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "52959092310", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "52959092320", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55111069990", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71335075506", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54569604201", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "63187093215", "ndc_label_name": "Cetirizine HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "63629370801", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71335030001", "ndc_label_name": "Cetirizine HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54569604203", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55289099590", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55289099510", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71610009360", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55289099530", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "63187093290", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65243036803", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71335030006", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60505263301", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "58118040208", "ndc_label_name": "Cetirizine HCl TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "61919053830", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71610012330", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "63629370804", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "63629370802", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71335075501", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68752000590", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "65243037003", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68788690509", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "63629370803", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68788690500", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68788079003", "ndc_label_name": "Cetirizine HCl TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71205020790", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71610004860", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71205020715", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68788690501", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71335075502", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68788690503", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71205020730", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71610012360", "ndc_label_name": "Cetirizine HCl Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "60505263201", "ndc_label_name": "Cetirizine HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "16571040110", "ndc_label_name": "Cetirizine HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00781168301", "ndc_label_name": "Cetirizine HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "55700033130", "ndc_label_name": "Cetirizine HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00378363501", "ndc_label_name": "Cetirizine HCl TABLET 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "71205009330", "ndc_label_name": "Cetirizine HCl Tablet 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00781528406", "ndc_label_name": "Cetirizine HCl Tablet Chewable 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "47335034483", "ndc_label_name": "Cetirizine HCl TABLET CHEWABLE 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00781528464", "ndc_label_name": "Cetirizine HCl TABLET CHEWABLE 10 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00781528364", "ndc_label_name": "Cetirizine HCl Tablet Chewable 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00781528306", "ndc_label_name": "Cetirizine HCl Tablet Chewable 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "47335034383", "ndc_label_name": "Cetirizine HCl TABLET CHEWABLE 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "45802072153", "ndc_label_name": "Cetirizine-Pseudoephedrine ER Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "53217008824", "ndc_label_name": "Cetirizine-Pseudoephedrine ER Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "45802072162", "ndc_label_name": "Cetirizine-Pseudoephedrine ER Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090253701", "ndc_label_name": "Cetirizine-Pseudoephedrine ER Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090109801", "ndc_label_name": "Cetirizine-Pseudoephedrine ER Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "63187095524", "ndc_label_name": "Cetirizine-Pseudoephedrine ER Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54569605501", "ndc_label_name": "Cetirizine-Pseudoephedrine ER Tablet Extended Release 12 Hour 5-120 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "35356001207", "ndc_label_name": "Chantix Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353089905", "ndc_label_name": "Chantix Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069046956", "ndc_label_name": "Chantix Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356001214", "ndc_label_name": "Chantix Tablet 1 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68462085229", "ndc_label_name": "Charlotte 24 Fe Tablet Chewable 1-20 MG-MCG(24) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462085284", "ndc_label_name": "Charlotte 24 Fe Tablet Chewable 1-20 MG-MCG(24) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102023021", "ndc_label_name": "Chateal EQ Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102023023", "ndc_label_name": "Chateal EQ Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102013001", "ndc_label_name": "Chateal Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102013003", "ndc_label_name": "Chateal Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102013048", "ndc_label_name": "Chateal Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102013090", "ndc_label_name": "Chateal TABLET 0.15-30 MG-MCG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50102013010", "ndc_label_name": "Chateal Tablet 0.15-30 MG-MCG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55292020111", "ndc_label_name": "Chemet CAPSULE 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50924014510", "ndc_label_name": "Chemstrip 10/SG STRIP IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "50924051510", "ndc_label_name": "Chemstrip K STRIP IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50924051310", "ndc_label_name": "Chemstrip uGK STRIP IN VITRO", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68974087640", "ndc_label_name": "Chenodal TABLET 250 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00536131485", "ndc_label_name": "Chest Congestion Relief Liquid 100 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "11694097601", "ndc_label_name": "Chew-C Tablet Chewable 500 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68094058862", "ndc_label_name": "Childrens Acetaminophen Suspension 325 MG/10.15ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "68094058859", "ndc_label_name": "Childrens Acetaminophen Suspension 325 MG/10.15ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00573017030", "ndc_label_name": "Childrens Advil SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00573017130", "ndc_label_name": "Childrens Advil SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00573023230", "ndc_label_name": "Childrens Advil SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00573020730", "ndc_label_name": "Childrens Advil SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00573029030", "ndc_label_name": "Childrens Advil SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00573017430", "ndc_label_name": "Childrens Advil Suspension 100 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00573029001", "ndc_label_name": "Childrens Advil SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00573170773", "ndc_label_name": "Childrens Advil SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205006372", "ndc_label_name": "Childrens Animal Shapes Tablet Chewable 18 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "62107002636", "ndc_label_name": "Childrens Aspirin Low Strength Tablet Chewable 81 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00904530909", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00472126394", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904557720", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00363066026", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "63874005312", "ndc_label_name": "Childrens Ibuprofen Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00472126194", "ndc_label_name": "Childrens Ibuprofen Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00121183605", "ndc_label_name": "Childrens Ibuprofen Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "17856530905", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142016626", "ndc_label_name": "Childrens Ibuprofen Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "00904530920", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800066026", "ndc_label_name": "Childrens Ibuprofen Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142089734", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142016634", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "41520031710", "ndc_label_name": "Childrens Ibuprofen Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800016626", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142066026", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "30142089726", "ndc_label_name": "Childrens Ibuprofen Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "45802013326", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205084826", "ndc_label_name": "Childrens Ibuprofen Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205064326", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68788981001", "ndc_label_name": "Childrens Ibuprofen Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54569915300", "ndc_label_name": "Childrens Ibuprofen Suspension 100 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "36800089726", "ndc_label_name": "Childrens Ibuprofen SUSPENSION 100 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68094050361", "ndc_label_name": "Childrens Ibuprofen Suspension 200 MG/10ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68094050359", "ndc_label_name": "Childrens Ibuprofen Suspension 200 MG/10ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68094050362", "ndc_label_name": "Childrens Ibuprofen Suspension 200 MG/10ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "50090145400", "ndc_label_name": "Childrens Loratadine Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68788729101", "ndc_label_name": "Childrens Loratadine Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51672208508", "ndc_label_name": "Childrens Loratadine Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "51672207308", "ndc_label_name": "Childrens Loratadine Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54838055840", "ndc_label_name": "Childrens Loratadine Solution 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "68788729101", "ndc_label_name": "Childrens Loratadine Syrup 5 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "54838014480", "ndc_label_name": "Childrens Silapap Liquid 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54838014470", "ndc_label_name": "Childrens Silapap Liquid 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "54838014440", "ndc_label_name": "Childrens Silapap Liquid 160 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63323001115", "ndc_label_name": "Chloramphenicol Sod Succinate SOLUTION RECONSTITUTED 1 GM Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555003302", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353096953", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555003305", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079037501", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291021190", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725160", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725190", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353069860", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079037520", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429055501", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025210", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025612", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353069830", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025640", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725191", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025620", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025601", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025614", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289006106", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025615", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353069853", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025624", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025610", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025625", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025602", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025630", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025621", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025660", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289006160", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071073460", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025608", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025650", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874025628", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725230", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725215", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725291", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725290", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725212", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725208", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725206", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555015902", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353069930", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063004615", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063004603", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353069953", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555015904", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063004612", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291021290", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217018330", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353069960", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079014120", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063004606", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079014101", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025310", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063004624", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063004619", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569209506", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999024420", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959088730", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999024410", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874027410", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919059330", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217018320", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999024430", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 25 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569209504", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429055601", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629402701", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629402702", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874027412", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610026353", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874027430", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 25 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079037401", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440725030", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999021450", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555015804", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51079037420", "ndc_label_name": "chlordiazePOXIDE HCl Capsule 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42291021090", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00555015802", "ndc_label_name": "ChlordiazePOXIDE HCl CAPSULE 5 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429055401", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43547025110", "ndc_label_name": "ChlordiazePOXIDE HCl Capsule 5 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00116200104", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69339013817", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135065024", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904703580", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904703587", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121089340", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00116200116", "ndc_label_name": "Chlorhexidine Gluconate SOLUTION 0.12 % MOUTH/THROAT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00116200115", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121089316", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571012848", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70166002603", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687071464", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17856200103", "ndc_label_name": "Chlorhexidine Gluconate SOLUTION 0.12 % MOUTH/THROAT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17856200203", "ndc_label_name": "Chlorhexidine Gluconate SOLUTION 0.12 % MOUTH/THROAT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121089300", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571012815", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66689010699", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135064947", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571012852", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135064941", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70166002715", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687071416", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17856200105", "ndc_label_name": "Chlorhexidine Gluconate SOLUTION 0.12 % MOUTH/THROAT", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739005257", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69339013815", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739005269", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090072200", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66689010650", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687061616", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788817304", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687061664", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69339013819", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135065051", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "81033051215", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66689010601", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "81033051250", "ndc_label_name": "Chlorhexidine Gluconate Solution 0.12 % Mouth/Throat", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143920910", "ndc_label_name": "Chloroprocaine HCl (PF) SOLUTION 2 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143920901", "ndc_label_name": "Chloroprocaine HCl (PF) SOLUTION 2 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143921001", "ndc_label_name": "Chloroprocaine HCl (PF) SOLUTION 3 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143921010", "ndc_label_name": "Chloroprocaine HCl (PF) SOLUTION 3 % Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440725304", "ndc_label_name": "Chloroquine Phosphate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980017750", "ndc_label_name": "Chloroquine Phosphate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304046050", "ndc_label_name": "Chloroquine Phosphate TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440725314", "ndc_label_name": "Chloroquine Phosphate Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063045440", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289085610", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440725404", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569523803", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143212522", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569523801", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289085640", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980017802", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569523800", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569523802", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304046126", "ndc_label_name": "Chloroquine Phosphate Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338041024", "ndc_label_name": "chlorproMAZINE HCl Concentrate 100 MG/ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781402822", "ndc_label_name": "chlorproMAZINE HCl Concentrate 100 MG/ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781402753", "ndc_label_name": "chlorproMAZINE HCl Concentrate 30 MG/ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24338040312", "ndc_label_name": "chlorproMAZINE HCl Concentrate 30 MG/ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794024942", "ndc_label_name": "chlorproMAZINE HCl Solution 25 MG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794024902", "ndc_label_name": "chlorproMAZINE HCl Solution 25 MG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598014011", "ndc_label_name": "chlorproMAZINE HCl Solution 25 MG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641139731", "ndc_label_name": "chlorproMAZINE HCl Solution 25 MG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710184907", "ndc_label_name": "chlorproMAZINE HCl Solution 25 MG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641139735", "ndc_label_name": "chlorproMAZINE HCl Solution 25 MG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150031825", "ndc_label_name": "chlorproMAZINE HCl Solution 25 MG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710184901", "ndc_label_name": "chlorproMAZINE HCl Solution 25 MG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598014025", "ndc_label_name": "chlorproMAZINE HCl Solution 25 MG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150031801", "ndc_label_name": "chlorproMAZINE HCl Solution 25 MG/ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150031901", "ndc_label_name": "chlorproMAZINE HCl Solution 50 MG/2ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641139835", "ndc_label_name": "chlorproMAZINE HCl Solution 50 MG/2ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55150031925", "ndc_label_name": "chlorproMAZINE HCl Solution 50 MG/2ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598014111", "ndc_label_name": "chlorproMAZINE HCl Solution 50 MG/2ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00641139831", "ndc_label_name": "chlorproMAZINE HCl Solution 50 MG/2ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710185007", "ndc_label_name": "chlorproMAZINE HCl Solution 50 MG/2ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794025042", "ndc_label_name": "chlorproMAZINE HCl Solution 50 MG/2ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598014125", "ndc_label_name": "chlorproMAZINE HCl Solution 50 MG/2ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66794025002", "ndc_label_name": "chlorproMAZINE HCl Solution 50 MG/2ML Injection", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030000", "ndc_label_name": "chlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079051801", "ndc_label_name": "chlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268016211", "ndc_label_name": "chlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781591301", "ndc_label_name": "chlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904689261", "ndc_label_name": "chlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079051820", "ndc_label_name": "chlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710112901", "ndc_label_name": "chlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687041901", "ndc_label_name": "ChlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268016215", "ndc_label_name": "chlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238105401", "ndc_label_name": "ChlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687041911", "ndc_label_name": "ChlorproMAZINE HCl Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268016515", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728630", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781591601", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904689561", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030310", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079051601", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030301", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728690", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710113201", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090286500", "ndc_label_name": "ChlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079051620", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030300", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356009890", "ndc_label_name": "ChlorproMAZINE HCl TABLET 100 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569908000", "ndc_label_name": "ChlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030389", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687045201", "ndc_label_name": "ChlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687045211", "ndc_label_name": "ChlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238106001", "ndc_label_name": "ChlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268016511", "ndc_label_name": "chlorproMAZINE HCl Tablet 100 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079051720", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238106201", "ndc_label_name": "ChlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268016612", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781591701", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079051701", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030400", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687046311", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030489", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687046301", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710113301", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030401", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030410", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904689661", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268016611", "ndc_label_name": "chlorproMAZINE HCl Tablet 200 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030101", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069621", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268016311", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781591401", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030189", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079051901", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069612", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030100", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904689361", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687043011", "ndc_label_name": "ChlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268016315", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030110", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710113001", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238105601", "ndc_label_name": "ChlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687043001", "ndc_label_name": "ChlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069610", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069601", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090279100", "ndc_label_name": "ChlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069628", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069620", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069630", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079051920", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069640", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569908900", "ndc_label_name": "ChlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069614", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069615", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069624", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874069660", "ndc_label_name": "chlorproMAZINE HCl Tablet 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781591501", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079013001", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030210", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728530", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728590", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030201", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049420", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904689461", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030200", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687044101", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049445", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00832030289", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079013020", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049414", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238105801", "ndc_label_name": "ChlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268016411", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268016415", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049421", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049415", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687044111", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049401", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049440", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049424", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049430", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049410", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710113101", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049412", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049460", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874049428", "ndc_label_name": "chlorproMAZINE HCl Tablet 50 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904690061", "ndc_label_name": "Chlorthalidone Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079005820", "ndc_label_name": "Chlorthalidone TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664064888", "ndc_label_name": "Chlorthalidone TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378022210", "ndc_label_name": "Chlorthalidone TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66689034599", "ndc_label_name": "Chlorthalidone Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079005801", "ndc_label_name": "Chlorthalidone TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378022201", "ndc_label_name": "Chlorthalidone TABLET 25 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980030301", "ndc_label_name": "Chlorthalidone TABLET 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714080001", "ndc_label_name": "Chlorthalidone Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834010901", "ndc_label_name": "Chlorthalidone Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980030310", "ndc_label_name": "Chlorthalidone TABLET 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904690004", "ndc_label_name": "Chlorthalidone Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598071910", "ndc_label_name": "Chlorthalidone Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834010910", "ndc_label_name": "Chlorthalidone Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382097001", "ndc_label_name": "Chlorthalidone Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598071901", "ndc_label_name": "Chlorthalidone Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687031725", "ndc_label_name": "Chlorthalidone TABLET 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687031795", "ndc_label_name": "Chlorthalidone TABLET 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162024709", "ndc_label_name": "Chlorthalidone Tablet 25 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378021310", "ndc_label_name": "Chlorthalidone TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378021301", "ndc_label_name": "Chlorthalidone TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834011010", "ndc_label_name": "Chlorthalidone Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598072001", "ndc_label_name": "Chlorthalidone Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382097101", "ndc_label_name": "Chlorthalidone Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980030401", "ndc_label_name": "Chlorthalidone TABLET 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162025009", "ndc_label_name": "Chlorthalidone Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57664064988", "ndc_label_name": "Chlorthalidone TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714080101", "ndc_label_name": "Chlorthalidone Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75834011001", "ndc_label_name": "Chlorthalidone Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66689034699", "ndc_label_name": "Chlorthalidone Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69499033060", "ndc_label_name": "Chlorzoxazone Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "46672086046", "ndc_label_name": "Chlorzoxazone Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24470092360", "ndc_label_name": "Chlorzoxazone Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980058206", "ndc_label_name": "Chlorzoxazone Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13811071710", "ndc_label_name": "Chlorzoxazone Tablet 375 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42494042510", "ndc_label_name": "Chlorzoxazone Tablet 375 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002114", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002107", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440727028", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440727040", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002120", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002121", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002128", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440727010", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002130", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569197002", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440727030", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591252005", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007330", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007320", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007390", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440727020", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999004414", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919047830", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00591252001", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002160", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999004410", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436344404", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999004418", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629158609", "ndc_label_name": "Chlorzoxazone TABLET 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999004415", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629158602", "ndc_label_name": "Chlorzoxazone TABLET 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002190", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007360", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999004430", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569197000", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090031503", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041924", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999004420", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041910", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569197005", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999004460", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002057610", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919047840", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090031600", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041956", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999004440", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041916", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289063328", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090031504", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002057630", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629158601", "ndc_label_name": "Chlorzoxazone TABLET 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569197001", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267005540", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999004490", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041942", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041901", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436344403", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002057640", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629158604", "ndc_label_name": "Chlorzoxazone TABLET 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629158605", "ndc_label_name": "Chlorzoxazone TABLET 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267005591", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090031500", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041908", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041914", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002057615", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569197003", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041950", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629158608", "ndc_label_name": "Chlorzoxazone TABLET 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569503001", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090031501", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66116063130", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041915", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289063308", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569197004", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267005500", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041904", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289063340", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002057620", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267005560", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041990", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187031730", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569647200", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629158607", "ndc_label_name": "Chlorzoxazone TABLET 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041921", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041940", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289063320", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041960", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267005520", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041972", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289063310", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66267005530", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041928", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629158603", "ndc_label_name": "Chlorzoxazone TABLET 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "73007001303", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289063317", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041974", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629158606", "ndc_label_name": "Chlorzoxazone TABLET 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041977", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289063324", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041912", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289063330", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041930", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919047890", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187031790", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874041920", "ndc_label_name": "Chlorzoxazone Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42494042810", "ndc_label_name": "Chlorzoxazone Tablet 750 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13811071810", "ndc_label_name": "Chlorzoxazone Tablet 750 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "11917016663", "ndc_label_name": "Chocolated Laxative TABLET CHEWABLE 15 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000047701", "ndc_label_name": "Chocolated Laxative Tablet Chewable 15 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00363000518", "ndc_label_name": "Chocolated Laxative TABLET CHEWABLE 15 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "40986002431", "ndc_label_name": "Chocolated Laxative TABLET CHEWABLE 15 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "49781004424", "ndc_label_name": "Chocolated Laxative Tablet Chewable 15 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "45043000202", "ndc_label_name": "Cholbam CAPSULE 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45043000102", "ndc_label_name": "Cholbam CAPSULE 50 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382052960", "ndc_label_name": "Cholestyramine Light PACKET 4 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884046665", "ndc_label_name": "Cholestyramine Light PACKET 4 GM ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185093998", "ndc_label_name": "Cholestyramine Light Packet 4 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884046663", "ndc_label_name": "Cholestyramine Light PACKET 4 GM ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185093997", "ndc_label_name": "Cholestyramine Light Powder 4 GM/DOSE Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884046667", "ndc_label_name": "Cholestyramine Light POWDER 4 GM/DOSE ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382052942", "ndc_label_name": "Cholestyramine Light POWDER 4 GM/DOSE Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00245053660", "ndc_label_name": "Cholestyramine Packet 4 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185094098", "ndc_label_name": "Cholestyramine Packet 4 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884046565", "ndc_label_name": "Cholestyramine PACKET 4 GM ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382052860", "ndc_label_name": "Cholestyramine Packet 4 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00245053689", "ndc_label_name": "Cholestyramine Packet 4 GM Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884046564", "ndc_label_name": "Cholestyramine PACKET 4 GM ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49884046566", "ndc_label_name": "Cholestyramine POWDER 4 GM/DOSE ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00185094097", "ndc_label_name": "Cholestyramine Powder 4 GM/DOSE Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00245053637", "ndc_label_name": "Cholestyramine Powder 4 GM/DOSE Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62559062037", "ndc_label_name": "Cholestyramine Powder 4 GM/DOSE Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382052842", "ndc_label_name": "Cholestyramine Powder 4 GM/DOSE Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323003011", "ndc_label_name": "Chorionic Gonadotropin SOLUTION RECONSTITUTED 10000 UNIT Intramuscular", "drug_tier": "Tier 4", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "75854032030", "ndc_label_name": "Chromagen CAPSULE ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00002446330", "ndc_label_name": "Cialis Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356041430", "ndc_label_name": "Cialis Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007430", "ndc_label_name": "Cialis Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569554400", "ndc_label_name": "Cialis Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071060608", "ndc_label_name": "Cialis Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071060610", "ndc_label_name": "Cialis Tablet 10 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00002446579", "ndc_label_name": "Cialis Tablet 2.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00002446534", "ndc_label_name": "Cialis Tablet 2.5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007510", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063023605", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569554500", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00002446430", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356013230", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353085706", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007530", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353085702", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629273405", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569554502", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629273402", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353085712", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353085704", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629273403", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629273401", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629273404", "ndc_label_name": "Cialis Tablet 20 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353004404", "ndc_label_name": "Cialis Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358007630", "ndc_label_name": "Cialis Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00002446230", "ndc_label_name": "Cialis Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00002446234", "ndc_label_name": "Cialis Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353004411", "ndc_label_name": "Cialis Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353004447", "ndc_label_name": "Cialis Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00002446279", "ndc_label_name": "Cialis Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353004418", "ndc_label_name": "Cialis Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353004408", "ndc_label_name": "Cialis Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353004423", "ndc_label_name": "Cialis Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069033530", "ndc_label_name": "Cibinqo Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069043530", "ndc_label_name": "Cibinqo Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00069023530", "ndc_label_name": "Cibinqo Tablet 50 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43538050006", "ndc_label_name": "Ciclodan SOLUTION 8 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168040799", "ndc_label_name": "Ciclopirox GEL 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47781053073", "ndc_label_name": "Ciclopirox Gel 0.77 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168040730", "ndc_label_name": "Ciclopirox GEL 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47781053085", "ndc_label_name": "Ciclopirox Gel 0.77 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574206130", "ndc_label_name": "Ciclopirox GEL 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462045535", "ndc_label_name": "Ciclopirox GEL 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168040746", "ndc_label_name": "Ciclopirox GEL 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574206101", "ndc_label_name": "Ciclopirox GEL 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462045547", "ndc_label_name": "Ciclopirox GEL 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462045594", "ndc_label_name": "Ciclopirox GEL 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47781053084", "ndc_label_name": "Ciclopirox Gel 0.77 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574206145", "ndc_label_name": "Ciclopirox GEL 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261076901", "ndc_label_name": "Ciclopirox Olamine Cream 0.77 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713063818", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999064615", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713063815", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802013818", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713063831", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802013811", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462029735", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462029717", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802013835", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672131808", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672131801", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002094563", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462029792", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672131802", "ndc_label_name": "Ciclopirox Olamine CREAM 0.77 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802040049", "ndc_label_name": "Ciclopirox Olamine SUSPENSION 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69315030960", "ndc_label_name": "Ciclopirox Olamine Suspension 0.77 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802040046", "ndc_label_name": "Ciclopirox Olamine SUSPENSION 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168031430", "ndc_label_name": "Ciclopirox Olamine SUSPENSION 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69315030930", "ndc_label_name": "Ciclopirox Olamine Suspension 0.77 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168031460", "ndc_label_name": "Ciclopirox Olamine Suspension 0.77 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672132304", "ndc_label_name": "Ciclopirox Olamine SUSPENSION 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672132303", "ndc_label_name": "Ciclopirox Olamine SUSPENSION 0.77 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802040109", "ndc_label_name": "Ciclopirox SHAMPOO 1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52565003212", "ndc_label_name": "Ciclopirox Shampoo 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591215990", "ndc_label_name": "Ciclopirox SHAMPOO 1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168052204", "ndc_label_name": "Ciclopirox Shampoo 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672135108", "ndc_label_name": "Ciclopirox SHAMPOO 1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118997001", "ndc_label_name": "Ciclopirox SHAMPOO 1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42192071506", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090656200", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135081445", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "21922005351", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713031788", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802014167", "ndc_label_name": "Ciclopirox SOLUTION 8 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788713806", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672530200", "ndc_label_name": "Ciclopirox SOLUTION 8 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629862301", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383041906", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788679706", "ndc_label_name": "Ciclopirox SOLUTION 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118997106", "ndc_label_name": "Ciclopirox SOLUTION 8 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162229802", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162132102", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162207601", "ndc_label_name": "Ciclopirox Solution 8 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42192071401", "ndc_label_name": "Ciclopirox Treatment Kit 8 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054004429", "ndc_label_name": "Cilostazol Tablet 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436005106", "ndc_label_name": "Cilostazol Tablet 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505252201", "ndc_label_name": "Cilostazol TABLET 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268017711", "ndc_label_name": "Cilostazol TABLET 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185022360", "ndc_label_name": "Cilostazol Tablet 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054004421", "ndc_label_name": "Cilostazol Tablet 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185022305", "ndc_label_name": "Cilostazol Tablet 100 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093206450", "ndc_label_name": "Cilostazol TABLET 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093206406", "ndc_label_name": "Cilostazol TABLET 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268017715", "ndc_label_name": "Cilostazol TABLET 100 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268017615", "ndc_label_name": "Cilostazol TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70436005006", "ndc_label_name": "Cilostazol Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00093206506", "ndc_label_name": "Cilostazol TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185012360", "ndc_label_name": "Cilostazol Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084077995", "ndc_label_name": "Cilostazol TABLET 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054002821", "ndc_label_name": "Cilostazol Tablet 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50268017611", "ndc_label_name": "Cilostazol TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505252101", "ndc_label_name": "Cilostazol TABLET 50 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084077925", "ndc_label_name": "Cilostazol TABLET 50 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118996703", "ndc_label_name": "Ciloxan OINTMENT 0.3 % OPHTHALMIC", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00065065435", "ndc_label_name": "Ciloxan Ointment 0.3 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569329600", "ndc_label_name": "Ciloxan Solution 0.3 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00065065605", "ndc_label_name": "Ciloxan Solution 0.3 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959001300", "ndc_label_name": "Ciloxan Solution 0.3 % Ophthalmic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49502045093", "ndc_label_name": "Cimduo Tablet 300-300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70114044001", "ndc_label_name": "Cimerli Solution 0.3 MG/0.05ML Intravitreal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61314062494", "ndc_label_name": "Cimerli Solution 0.3 MG/0.05ML Intravitreal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70114044101", "ndc_label_name": "Cimerli Solution 0.5 MG/0.05ML Intravitreal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61314062594", "ndc_label_name": "Cimerli Solution 0.5 MG/0.05ML Intravitreal", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "62135080937", "ndc_label_name": "Cimetidine HCl Solution 300 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121064908", "ndc_label_name": "Cimetidine HCl Solution 300 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383096608", "ndc_label_name": "Cimetidine HCl Solution 300 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50383005008", "ndc_label_name": "Cimetidine HCl Solution 300 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121064940", "ndc_label_name": "Cimetidine HCl Solution 300 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135080924", "ndc_label_name": "Cimetidine HCl Solution 300 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62135080905", "ndc_label_name": "Cimetidine HCl Solution 300 MG/5ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00121129840", "ndc_label_name": "Cimetidine HCl Solution 400 MG/6.67ML Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505001806", "ndc_label_name": "Cimetidine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378005301", "ndc_label_name": "Cimetidine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874002010", "ndc_label_name": "Cimetidine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874002028", "ndc_label_name": "Cimetidine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874002015", "ndc_label_name": "Cimetidine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874002001", "ndc_label_name": "Cimetidine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874002020", "ndc_label_name": "Cimetidine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49614012055", "ndc_label_name": "Cimetidine TABLET 200 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "63874002004", "ndc_label_name": "Cimetidine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874002030", "ndc_label_name": "Cimetidine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874002045", "ndc_label_name": "Cimetidine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874002060", "ndc_label_name": "Cimetidine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874002090", "ndc_label_name": "Cimetidine Tablet 200 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093819201", "ndc_label_name": "Cimetidine TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728104", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728108", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093819205", "ndc_label_name": "Cimetidine TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261063090", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728130", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378031701", "ndc_label_name": "Cimetidine TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728160", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728192", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544062730", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728115", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007760", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007730", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728191", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728194", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999011214", "ndc_label_name": "Cimetidine TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034530", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291021790", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261063060", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505001906", "ndc_label_name": "Cimetidine TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999011230", "ndc_label_name": "Cimetidine TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261063030", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261063002", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005630", "ndc_label_name": "Cimetidine TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034540", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505001904", "ndc_label_name": "Cimetidine TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034512", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038901", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569383700", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034560", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999011221", "ndc_label_name": "Cimetidine TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038921", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038910", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629178301", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034520", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038960", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569383702", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629178302", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034500", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038930", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038920", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038974", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760019290", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289079910", "ndc_label_name": "Cimetidine TABLET 300 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034535", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289079960", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038940", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038950", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959034590", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038972", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760019230", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038990", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038904", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038912", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874038977", "ndc_label_name": "Cimetidine Tablet 300 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728230", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037515", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378037201", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037514", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999034860", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728206", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093820405", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093820401", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728260", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037528", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440128260", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039004", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090050000", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728290", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728220", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728215", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728291", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037550", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728292", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039009", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037502", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289058110", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007860", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037560", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007830", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569383801", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544062630", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039015", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037516", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289058130", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999034830", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037590", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291021801", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289058160", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090050001", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149702", "ndc_label_name": "Cimetidine TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037530", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505002004", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037500", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039024", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289058128", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149701", "ndc_label_name": "Cimetidine TABLET 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039005", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039040", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864010828", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149704", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037520", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039050", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289058190", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039001", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039014", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005730", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039003", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039010", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037540", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005760", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505002008", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039016", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039060", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788906403", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039012", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039020", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569383800", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039030", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039074", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039032", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039080", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039090", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289058120", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039077", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58437000218", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788906406", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505002006", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149703", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039021", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039028", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039045", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039072", "ndc_label_name": "Cimetidine Tablet 400 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66685170303", "ndc_label_name": "Cimetidine TABLET 400 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728330", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289052807", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728390", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728315", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037600", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378054101", "ndc_label_name": "Cimetidine TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00093830501", "ndc_label_name": "Cimetidine TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358007930", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728391", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505002107", "ndc_label_name": "Cimetidine TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039120", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037630", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037620", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440728360", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505002103", "ndc_label_name": "Cimetidine TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037640", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037616", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149503", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267025830", "ndc_label_name": "Cimetidine TABLET 800 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58437000321", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959037660", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039109", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149502", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864010930", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569383900", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039101", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149504", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039107", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629149501", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039110", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039172", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039160", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58437000313", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039170", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039177", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039130", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039104", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039174", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039112", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039190", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039115", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874039124", "ndc_label_name": "Cimetidine Tablet 800 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50474071079", "ndc_label_name": "Cimzia (2 Syringe) Prefilled Syringe Kit 200 MG/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474070062", "ndc_label_name": "Cimzia KIT 2 X 200 MG Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474071081", "ndc_label_name": "Cimzia Starter Kit Prefilled Syringe Kit 6 X 200 MG/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50474071081", "ndc_label_name": "Cimzia-Starter Prefilled Syringe Kit 200 MG/ML Subcutaneous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "51407029530", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904706704", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291045930", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722010330", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268015311", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862083105", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729044010", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378619793", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76282067430", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714007801", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268015312", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877050330", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862083130", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71093015201", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598036730", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729044015", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687052511", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72865015030", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629876301", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42543096104", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629960801", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335037983", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70436000704", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687052521", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097041002", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380088304", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162184303", "ndc_label_name": "Cinacalcet HCl Tablet 30 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862083205", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729044110", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378619693", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407029630", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76282067530", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714007901", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380088404", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729044115", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862083230", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42543096204", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70436000804", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877050430", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097041102", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722010430", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162184403", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291046030", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629876401", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72865015130", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598036830", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71093015301", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335038083", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629960701", "ndc_label_name": "Cinacalcet HCl Tablet 60 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378619593", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862083330", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598036930", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729044210", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714008001", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729044215", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629876501", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70436000904", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42543096304", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71093015401", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51407029730", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69097041202", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47335060083", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "31722010530", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629960601", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "76282067630", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67877050530", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291046130", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72865015230", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162184503", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380088504", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862083305", "ndc_label_name": "Cinacalcet HCl Tablet 90 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59310061031", "ndc_label_name": "Cinqair SOLUTION 100 MG/10ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42227008105", "ndc_label_name": "Cinryze Solution Reconstituted 500 UNIT Intravenous", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "47426020101", "ndc_label_name": "Cinvanti EMULSION 130 MG/18ML Intravenous", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00065853110", "ndc_label_name": "Cipro HC Suspension 0.2-1 % Otic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356052710", "ndc_label_name": "Cipro HC SUSPENSION 0.2-1 % OTIC", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090165600", "ndc_label_name": "Cipro HC Suspension 0.2-1 % Otic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959072510", "ndc_label_name": "Cipro HC Suspension 0.2-1 % Otic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569472300", "ndc_label_name": "Cipro HC Suspension 0.2-1 % Otic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419077701", "ndc_label_name": "Cipro Suspension Reconstituted 250 MG/5ML (5%) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419077301", "ndc_label_name": "Cipro Suspension Reconstituted 500 MG/5ML (10%) Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959017110", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959017120", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289045914", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959017128", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289045912", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959017114", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289045906", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419075801", "ndc_label_name": "Cipro TABLET 250 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289045910", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569164805", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864077520", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959017106", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116019114", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569164807", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116019106", "ndc_label_name": "Cipro Tablet 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419075401", "ndc_label_name": "Cipro TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006107", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569172301", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006104", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003610", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006114", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006120", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289037130", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003614", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006125", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289037103", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999006110", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003628", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569172302", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003606", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289037150", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003615", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003630", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289037110", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569172300", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569172305", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289037106", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959003620", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864063730", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864063714", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010701", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010712", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289037114", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010760", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289037115", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289037179", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010750", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864063720", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010714", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010740", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289037140", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010702", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289037120", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010706", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116019214", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010710", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010728", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105010901", "ndc_label_name": "Cipro TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010715", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105010903", "ndc_label_name": "Cipro TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010704", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010708", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116019260", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116068814", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116042320", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105010906", "ndc_label_name": "Cipro TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010716", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010709", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010720", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116019206", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105010902", "ndc_label_name": "Cipro TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010730", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005810", "ndc_label_name": "Cipro TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005814", "ndc_label_name": "Cipro TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874010790", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66105010910", "ndc_label_name": "Cipro TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116019230", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66116068920", "ndc_label_name": "Cipro Tablet 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267005820", "ndc_label_name": "Cipro TABLET 500 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00065853302", "ndc_label_name": "Ciprodex Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217007401", "ndc_label_name": "Ciprodex Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569556000", "ndc_label_name": "Ciprodex Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205030975", "ndc_label_name": "Ciprodex Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42195055014", "ndc_label_name": "Ciprofloxacin HCl Solution 0.2 % Otic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478071410", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090088100", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788819801", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571012025", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436065601", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090230200", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571012050", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090422000", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002132002", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090175400", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "17478071425", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999069925", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59390021710", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959055705", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090231000", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436071401", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314065605", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314065625", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090318400", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090088200", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919042105", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700073705", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919049105", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59390021702", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919079505", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71205030005", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788939105", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090421700", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788710005", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118996805", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187015005", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59390021705", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187098505", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61314065610", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788819805", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436021001", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69315030805", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919079525", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002132001", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69315030810", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187098510", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69315030802", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518204500", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70518239000", "ndc_label_name": "Ciprofloxacin HCl Solution 0.3 % Ophthalmic", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111012506", "ndc_label_name": "Ciprofloxacin HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008001", "ndc_label_name": "Ciprofloxacin HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008006", "ndc_label_name": "Ciprofloxacin HCl Tablet 100 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729006", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629001", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729014", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544014714", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629020", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143992701", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039910", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00172531160", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060420", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629014", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729040", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060306", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544014706", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544014710", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039920", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729002", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356092806", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629040", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16252051401", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714065102", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002027906", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060310", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039960", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729020", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090316000", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039928", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039906", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039914", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569558400", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571041110", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063041010", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060406", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073910", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063041014", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039921", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356092810", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919037106", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039912", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086700", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060414", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002027914", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073906", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063041006", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291021901", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071005514", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063041012", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086701", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039907", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111012601", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700027920", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999033314", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086702", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071005528", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999033320", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090316002", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261039930", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082306", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864080606", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569558402", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090316001", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788900602", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073914", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002027910", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063041020", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132605", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132607", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55154208600", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073920", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335040800", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082314", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002027920", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090322100", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739070010", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132608", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700074420", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569914600", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335040805", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700027906", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111012605", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569558401", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071005510", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084006901", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862007601", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082320", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082312", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700027910", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335040801", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760051210", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700074406", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335040803", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335083603", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700027914", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132601", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700074410", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132603", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760051214", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132604", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335040804", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071005520", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864080614", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69117000801", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760051221", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934006806", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919037120", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335040802", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335040809", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335040807", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864080620", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335040808", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442022201", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72789000606", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919037114", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442022210", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132602", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919037102", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64205092714", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629132606", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071005506", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071005521", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071005530", "ndc_label_name": "Ciprofloxacin HCl TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084006911", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788972402", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335040806", "ndc_label_name": "Ciprofloxacin HCl Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378709801", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00179198206", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143992801", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00179198220", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143203701", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629105", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00172531270", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629101", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629181", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00179198214", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00172531260", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729106", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629130", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729104", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629114", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629120", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544007914", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629110", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729120", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729110", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729102", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729191", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629160", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729114", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060520", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060620", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904637861", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729130", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544003606", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060706", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440629191", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544007906", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060710", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060720", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060610", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24658025005", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060814", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060810", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729160", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060714", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094314", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544088420", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544088406", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016402", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714065202", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060820", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544043210", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060806", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714065204", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24658025011", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16252051501", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016420", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016406", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016413", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544060614", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544094320", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24658025020", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24658025060", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "24658025001", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016440", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016407", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016414", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571041210", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "13107007701", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016416", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063042720", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016401", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008130", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016410", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016442", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008101", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571041250", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016428", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054710", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016421", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356084606", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016424", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008110", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008106", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016460", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054706", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054730", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008128", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356084614", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261016430", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063005306", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092328", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356073320", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054720", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063086920", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008160", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054704", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008114", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063042710", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090164807", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356073330", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063086930", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092314", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356084610", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054728", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008120", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063042730", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090164808", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063005304", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999033401", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086300", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356084620", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063086906", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063042703", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054701", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073004", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063042706", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090164805", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086301", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356084630", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086400", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063042704", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054714", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073006", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086308", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436604101", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090164803", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063042728", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090164801", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063042714", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092310", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002026420", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073000", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073014", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090164804", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063042779", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090313000", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054702", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092320", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018624", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073015", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073060", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50436604102", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063086908", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569557403", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054703", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086304", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082110", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073028", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018607", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079018220", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092306", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111012705", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063054779", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086305", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082140", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002026410", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569557404", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073010", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063092330", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700060820", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063086910", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086307", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60429004220", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018613", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569557405", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073020", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090164900", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760081506", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090086303", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090164800", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919005406", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018628", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700060830", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002026401", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51079018201", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442022305", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002026430", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002026406", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919005420", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569557408", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118012708", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018620", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073021", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919005414", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018601", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002026414", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919036110", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082130", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760081514", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569557407", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073030", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919005460", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018614", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018610", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187001720", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700060814", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760081520", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082106", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018606", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187025020", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53217018616", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569831100", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629172403", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864083310", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760081530", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700048114", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569831800", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629172408", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569557400", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082103", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874108602", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864083320", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629172402", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700060806", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082150", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739055910", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569557401", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082179", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874108605", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874108604", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629172405", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629172404", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760007410", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64205092814", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111012701", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700060810", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267091914", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788902401", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084007011", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874108601", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760007420", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788902402", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082114", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919005430", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788901201", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788902408", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004514", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862007701", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760081510", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934009306", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082120", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187001714", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934009314", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335007006", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610008118", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267091910", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919005410", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629172407", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442022301", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267091928", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335007001", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629172410", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187025014", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267091960", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629172401", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874108603", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629172406", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788901202", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335007007", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69117000902", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629172409", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788901208", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63874108606", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004506", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788922802", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788902400", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335007008", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004520", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335007005", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335007000", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267091906", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335007002", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335007009", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610008183", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267091920", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610015983", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66267091930", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084007001", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788901200", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69117000901", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70934004510", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335007003", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335007004", "ndc_label_name": "Ciprofloxacin HCl TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71610010930", "ndc_label_name": "Ciprofloxacin HCl Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036707", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00172531360", "ndc_label_name": "Ciprofloxacin HCl TABLET 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082620", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036721", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143992950", "ndc_label_name": "Ciprofloxacin HCl TABLET 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036710", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729220", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16571041305", "ndc_label_name": "Ciprofloxacin HCl TABLET 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356026410", "ndc_label_name": "Ciprofloxacin HCl TABLET 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036760", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629386801", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063076728", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036728", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036720", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16252051605", "ndc_label_name": "Ciprofloxacin HCl TABLET 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862007850", "ndc_label_name": "Ciprofloxacin HCl TABLET 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289082610", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073414", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071033130", "ndc_label_name": "Ciprofloxacin HCl TABLET 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073460", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073420", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505131001", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714065301", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071033120", "ndc_label_name": "Ciprofloxacin HCl TABLET 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187099030", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61442022450", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036714", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55111012850", "ndc_label_name": "Ciprofloxacin HCl TABLET 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629386803", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187099010", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261036730", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629386802", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959073430", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629386806", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629386804", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071033114", "ndc_label_name": "Ciprofloxacin HCl TABLET 750 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629386805", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084007101", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084007111", "ndc_label_name": "Ciprofloxacin HCl Tablet 750 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409477711", "ndc_label_name": "Ciprofloxacin in D5W Solution 200 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409230001", "ndc_label_name": "Ciprofloxacin in D5W Solution 200 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409230024", "ndc_label_name": "Ciprofloxacin in D5W Solution 200 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "36000000824", "ndc_label_name": "Ciprofloxacin in D5W Solution 200 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409477723", "ndc_label_name": "Ciprofloxacin in D5W Solution 200 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021019282", "ndc_label_name": "Ciprofloxacin in D5W Solution 200 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021011482", "ndc_label_name": "Ciprofloxacin in D5W Solution 200 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "36000029724", "ndc_label_name": "Ciprofloxacin in D5W Solution 200 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409330001", "ndc_label_name": "Ciprofloxacin in D5W Solution 400 MG/200ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409330024", "ndc_label_name": "Ciprofloxacin in D5W Solution 400 MG/200ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409477721", "ndc_label_name": "Ciprofloxacin in D5W Solution 400 MG/200ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00409477702", "ndc_label_name": "Ciprofloxacin in D5W Solution 400 MG/200ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021011487", "ndc_label_name": "Ciprofloxacin in D5W Solution 400 MG/200ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "36000000924", "ndc_label_name": "Ciprofloxacin in D5W Solution 400 MG/200ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021019287", "ndc_label_name": "Ciprofloxacin in D5W Solution 400 MG/200ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "36000029824", "ndc_label_name": "Ciprofloxacin in D5W Solution 400 MG/200ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781618667", "ndc_label_name": "Ciprofloxacin-Dexamethasone Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714062801", "ndc_label_name": "Ciprofloxacin-Dexamethasone Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53746083153", "ndc_label_name": "Ciprofloxacin-Dexamethasone Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "62756042790", "ndc_label_name": "Ciprofloxacin-Dexamethasone Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43598032675", "ndc_label_name": "Ciprofloxacin-Dexamethasone Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72485062513", "ndc_label_name": "Ciprofloxacin-Dexamethasone Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629879701", "ndc_label_name": "Ciprofloxacin-Dexamethasone Suspension 0.3-0.1 % Otic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52536008014", "ndc_label_name": "Ciprofloxacin-Fluocinolone PF Solution 0.3-0.025 % Otic", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703574811", "ndc_label_name": "CISplatin SOLUTION 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001028333", "ndc_label_name": "CISplatin Solution 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021025351", "ndc_label_name": "CISplatin Solution 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143950501", "ndc_label_name": "CISplatin Solution 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729028838", "ndc_label_name": "CISplatin SOLUTION 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323010365", "ndc_label_name": "CISplatin SOLUTION 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567051001", "ndc_label_name": "CISplatin Solution 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860020651", "ndc_label_name": "CISplatin Solution 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001028332", "ndc_label_name": "CISplatin Solution 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72266025301", "ndc_label_name": "CISplatin Solution 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001060933", "ndc_label_name": "CISplatin Solution 100 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567051101", "ndc_label_name": "CISplatin SOLUTION 200 MG/200ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323010364", "ndc_label_name": "CISplatin SOLUTION 200 MG/200ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00143950401", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "25021025350", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "47781060925", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567050901", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00703574711", "ndc_label_name": "CISplatin SOLUTION 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16729028811", "ndc_label_name": "CISplatin SOLUTION 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505627900", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323010351", "ndc_label_name": "CISplatin SOLUTION 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001060824", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70860020650", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001028324", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505627700", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68001028327", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72266025201", "ndc_label_name": "CISplatin Solution 50 MG/50ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "44567053001", "ndc_label_name": "CISplatin Solution Reconstituted 50 MG Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52427069130", "ndc_label_name": "Citalopram Hydrobromide Capsule 30 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121169640", "ndc_label_name": "Citalopram Hydrobromide Solution 10 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00121169610", "ndc_label_name": "Citalopram Hydrobromide Solution 10 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00054006258", "ndc_label_name": "Citalopram Hydrobromide SOLUTION 10 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862007424", "ndc_label_name": "Citalopram Hydrobromide SOLUTION 10 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722056424", "ndc_label_name": "Citalopram Hydrobromide SOLUTION 10 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54838054070", "ndc_label_name": "Citalopram Hydrobromide Solution 10 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "17856007401", "ndc_label_name": "Citalopram Hydrobromide SOLUTION 10 MG/5ML ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60258083008", "ndc_label_name": "Citalopram Hydrobromide Solution 10 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440729590", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002690", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378623105", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185037101", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668000901", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107000501", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378623101", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00713474001", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668000905", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358008290", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002614", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904608461", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668000930", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668000909", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00713474005", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356002830", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002607", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063024930", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358008260", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107000505", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090129802", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002628", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002630", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034205", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002660", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090129800", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569632200", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002620", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090252002", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806001901", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458098116", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664050788", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358008230", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569632201", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700078790", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002621", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959060330", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090252000", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746054301", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505251808", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063048105", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700014860", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118050703", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806001910", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569632202", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002157903", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505251803", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162005250", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034201", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700014890", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760000930", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090129801", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664050713", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458098112", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162005203", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000505", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034230", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429017310", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681001", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090252001", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746054305", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760000990", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681008", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000510", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700014830", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629333801", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429017301", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700078730", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505251804", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000530", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429017330", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681006", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919025930", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162005210", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187022090", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505251801", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919028830", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084073711", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629333803", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681009", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282020601", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788681003", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084073701", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629333802", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282020690", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645056954", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282020610", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097082212", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097082207", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000501", "ndc_label_name": "Citalopram Hydrobromide TABLET 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282062810", "ndc_label_name": "Citalopram Hydrobromide Tablet 10 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378623205", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00713474101", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544000630", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00713474105", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185037201", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544014930", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544017960", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440729330", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440729390", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668001030", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063006330", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107000601", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378623201", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668001001", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668001006", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544017930", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904608561", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358008330", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353011645", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063006360", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544017990", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002790", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002760", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002730", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107000605", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063006314", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353064260", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063006390", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668001005", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806002001", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356072090", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358008360", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "35356072030", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090324703", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959077360", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090277400", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "31722020710", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353020860", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806002010", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063068390", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063068360", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959077330", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002135906", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090324700", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063068330", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353064245", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353064215", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090250101", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353011660", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217019130", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569906200", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090324702", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353011615", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090250103", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353077815", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217019100", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353020845", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458098010", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289088390", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436091602", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353020815", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090324701", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090250102", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217019190", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353077845", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569562603", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700035630", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002135900", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353020830", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289088330", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569562600", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034330", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353077860", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034301", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664050813", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034305", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353077830", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700035690", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629131801", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118050806", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458098016", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289088360", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746054405", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289088314", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090250100", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118050803", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162005303", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118116603", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664050818", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919005690", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429017401", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864087730", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959077352", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118111606", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934012730", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919005630", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118050809", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629131804", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505251908", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505251901", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002135903", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864087714", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335023803", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629131802", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429017410", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "64205020730", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919038930", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505251904", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53217019160", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187020360", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335023804", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162005310", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760049590", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000630", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874111303", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760049530", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569562601", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162005350", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282020701", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000605", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919005660", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071023190", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874111306", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919038960", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569562602", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000601", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000610", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645057054", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874111301", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084074411", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68084074401", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788080209", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664050888", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335023801", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009260", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097082312", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071023160", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335023805", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746054401", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009230", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788080203", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335023806", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429017430", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009245", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282020790", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71610009215", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505251903", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335071203", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282062910", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282020710", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919038990", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629131803", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071023130", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071023152", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788000503", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097082307", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335023802", "ndc_label_name": "Citalopram Hydrobromide TABLET 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335071201", "ndc_label_name": "Citalopram Hydrobromide Tablet 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378623305", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440729415", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544015030", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00185037301", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440729490", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440729430", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00378623301", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107000705", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668001108", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00713474205", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002890", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00713474201", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544018230", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00440729445", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668001105", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668001101", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358008430", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00904608661", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063022190", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063022130", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "10544018290", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13107000701", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "13668001130", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002860", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353011253", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063022101", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353009130", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063038530", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002800", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002814", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33261002830", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806002101", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959098630", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353011230", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353048115", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353011215", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057345", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358008460", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "42806002110", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063038501", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864081215", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090273200", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057360", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353011245", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999065430", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063067030", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063038590", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353011260", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505252004", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090273202", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090273201", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057330", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090320800", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353048145", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664050988", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353048173", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505252008", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090313602", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090288800", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700032430", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50436091701", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43353057315", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118474209", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034405", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162005450", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090320802", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090320801", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58118474203", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458088910", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999065490", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746054601", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "59746054605", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544036030", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569562702", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002136000", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63187014030", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54458088916", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090313600", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429017530", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60760049690", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544090645", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569910500", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002136006", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282020801", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569562701", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "53002136003", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919039090", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645046754", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544090673", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664050918", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569562700", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700032490", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034401", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429017501", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243031903", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55700083890", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645028254", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60429017510", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55111034430", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58517010030", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919039030", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162005403", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243031909", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505252001", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896209", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65162005410", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "57664050913", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "61919048030", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874115703", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243031009", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544090630", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63629331701", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "71335048001", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896203", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864081230", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "63874115700", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243021103", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097082412", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544090653", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243030203", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243021109", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "70934009030", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "60505252003", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243031003", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243038145", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282020810", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544090660", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243031015", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243038445", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68071022230", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243030209", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645057154", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000705", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896208", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000710", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243031945", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544090615", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69097082407", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645051454", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65243038409", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "76282020890", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000701", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "65862000730", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "67544090671", "ndc_label_name": "Citalopram Hydrobromide Tablet 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68645055954", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896201", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "68788896206", "ndc_label_name": "Citalopram Hydrobromide TABLET 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "16500054562", "ndc_label_name": "Citracal Calcium Gummies Tablet Chewable 250-115-250 MG-MG-UNIT Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16500053536", "ndc_label_name": "Citracal Maximum Plus Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16500053505", "ndc_label_name": "Citracal Maximum Plus Tablet Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16500053504", "ndc_label_name": "Citracal Maximum TABLET 315-250 MG-UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00178081512", "ndc_label_name": "Citracal Maximum TABLET 315-250 MG-UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00178081560", "ndc_label_name": "Citracal Maximum TABLET 315-250 MG-UNIT ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16500053457", "ndc_label_name": "Citracal Maximum Tablet 315-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16500053502", "ndc_label_name": "Citracal Petites/Vitamin D Tablet 200-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "16500053503", "ndc_label_name": "Citracal Petites/Vitamin D Tablet 200-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00178082130", "ndc_label_name": "CitraNatal 90 DHA 90-1 & 300 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00178089130", "ndc_label_name": "CitraNatal Assure 35-1 & 300 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00178083230", "ndc_label_name": "CitraNatal B-Calm 20-1 MG & 2 x 25 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00178081330", "ndc_label_name": "CitraNatal Bloom Tablet 90-1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00178089430", "ndc_label_name": "CitraNatal DHA 27-1 & 250 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00178079630", "ndc_label_name": "CitraNatal Harmony CAPSULE 27-1-260 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00178085890", "ndc_label_name": "CitraNatal Rx Tablet 27-1 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00536322301", "ndc_label_name": "Citrus Calcium/Vitamin D Tablet 200-6.25 MG-MCG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00143987101", "ndc_label_name": "Cladribine Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "67457045010", "ndc_label_name": "Cladribine Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42658001091", "ndc_label_name": "Cladribine Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63323014010", "ndc_label_name": "Cladribine SOLUTION 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42658001001", "ndc_label_name": "Cladribine Solution 10 MG/10ML Intravenous", "drug_tier": "Tier 4", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555105456", "ndc_label_name": "Claravis CAPSULE 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555105486", "ndc_label_name": "Claravis CAPSULE 10 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555105556", "ndc_label_name": "Claravis Capsule 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868630700", "ndc_label_name": "Claravis CAPSULE 20 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555105586", "ndc_label_name": "Claravis Capsule 20 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555105686", "ndc_label_name": "Claravis Capsule 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555105660", "ndc_label_name": "Claravis Capsule 30 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555105756", "ndc_label_name": "Claravis Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54868630800", "ndc_label_name": "Claravis CAPSULE 40 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00555105786", "ndc_label_name": "Claravis Capsule 40 MG Oral", "drug_tier": "Tier 1", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569535202", "ndc_label_name": "Clarinex Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999041000", "ndc_label_name": "Clarinex TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959068510", "ndc_label_name": "Clarinex Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00085126401", "ndc_label_name": "Clarinex Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959068530", "ndc_label_name": "Clarinex Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "33358008530", "ndc_label_name": "Clarinex Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999041010", "ndc_label_name": "Clarinex TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "55289092510", "ndc_label_name": "Clarinex Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105080703", "ndc_label_name": "Clarinex TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999041090", "ndc_label_name": "Clarinex TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "52959068590", "ndc_label_name": "Clarinex Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999041014", "ndc_label_name": "Clarinex TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105080715", "ndc_label_name": "Clarinex TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50090076500", "ndc_label_name": "Clarinex Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "49999041030", "ndc_label_name": "Clarinex TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54569535200", "ndc_label_name": "Clarinex Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "58864070330", "ndc_label_name": "Clarinex Tablet 5 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105080709", "ndc_label_name": "Clarinex TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105080701", "ndc_label_name": "Clarinex TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "66105080706", "ndc_label_name": "Clarinex TABLET 5 MG ORAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "00085132201", "ndc_label_name": "Clarinex-D 12 Hour Tablet Extended Release 12 Hour 2.5-120 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "43063052014", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729740", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729714", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729702", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629128402", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729704", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729720", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729728", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063094214", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42291026360", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261080820", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527193006", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261080830", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629128403", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629128401", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090141000", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591280560", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569647600", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51862019460", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569831300", "ndc_label_name": "Clarithromycin ER Tablet Extended Release 24 Hour 500 MG Oral", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382076405", "ndc_label_name": "Clarithromycin SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781602246", "ndc_label_name": "Clarithromycin SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781602252", "ndc_label_name": "Clarithromycin SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382076406", "ndc_label_name": "Clarithromycin SUSPENSION RECONSTITUTED 125 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090099400", "ndc_label_name": "Clarithromycin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781602346", "ndc_label_name": "Clarithromycin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781602352", "ndc_label_name": "Clarithromycin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382076506", "ndc_label_name": "Clarithromycin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569582900", "ndc_label_name": "Clarithromycin Suspension Reconstituted 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382076505", "ndc_label_name": "Clarithromycin SUSPENSION RECONSTITUTED 250 MG/5ML Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054003621", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729628", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527193106", "ndc_label_name": "Clarithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729620", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729604", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261063120", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "35356002514", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00440729614", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268017815", "ndc_label_name": "Clarithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781196160", "ndc_label_name": "Clarithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090329800", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380090503", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59746074260", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090244100", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569568800", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862022560", "ndc_label_name": "Clarithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237004460", "ndc_label_name": "Clarithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505261606", "ndc_label_name": "Clarithromycin Tablet 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268017811", "ndc_label_name": "Clarithromycin TABLET 250 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382076114", "ndc_label_name": "Clarithromycin TABLET 250 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063075228", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053020", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261061810", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00054003721", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527193206", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904687204", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10544095220", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781196260", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090319302", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090319301", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261061830", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261061828", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261061820", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261061890", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063053014", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261061814", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959083614", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959083620", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261061860", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082328", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999090414", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063082320", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063075220", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33358008620", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002075620", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002075610", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090183001", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090251500", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268017913", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959083610", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999090420", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43063075214", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629288704", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "57237004560", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090319300", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268017911", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289090928", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959083660", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "49999090430", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090183000", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788712503", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629288701", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289090910", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "53002075614", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071033720", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569569801", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090251501", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090183002", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788739203", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788642503", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053520", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289090920", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68382076214", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569569802", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090251502", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053514", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335001703", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58864083720", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60505261506", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919064320", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788693608", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59746074360", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569569800", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55700053530", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335001705", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919064310", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760026114", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071033730", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335001708", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "61919064328", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "55289090914", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60760026120", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335079505", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63187037628", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862022660", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084065125", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687043511", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629288703", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788693603", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63629288702", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "60687043521", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64380090603", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788739202", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084065195", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68071033714", "ndc_label_name": "Clarithromycin TABLET 500 MG ORAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788693602", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335001702", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788712508", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788642501", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788712502", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335001707", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788642502", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788693601", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335001701", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788739201", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788642508", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335001704", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788712501", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "71335001706", "ndc_label_name": "Clarithromycin TABLET 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68788739208", "ndc_label_name": "Clarithromycin Tablet 500 MG Oral", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "94542005830", "ndc_label_name": "Cleanlet Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "94542005835", "ndc_label_name": "Cleanlet Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "69978000004", "ndc_label_name": "ClearDetect COVID-19 AG Home Kit In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "37205061271", "ndc_label_name": "ClearLax Powder 17 GM/SCOOP Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205061272", "ndc_label_name": "ClearLax Powder 17 GM/SCOOP Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800030602", "ndc_label_name": "ClearLax Powder 17 GM/SCOOP Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800030601", "ndc_label_name": "ClearLax Powder 17 GM/SCOOP Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000041503", "ndc_label_name": "ClearLax Powder 17 GM/SCOOP Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "37205061273", "ndc_label_name": "ClearLax Powder 17 GM/SCOOP Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800018104", "ndc_label_name": "ClearLax Powder 17 GM/SCOOP Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000041501", "ndc_label_name": "ClearLax Powder 17 GM/SCOOP Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "36800030603", "ndc_label_name": "ClearLax Powder 17 GM/SCOOP Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "70000041502", "ndc_label_name": "ClearLax Powder 17 GM/SCOOP Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": true }, { "ndc": "00009344801", "ndc_label_name": "Cleocin CREAM 2 % VAGINAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569372300", "ndc_label_name": "Cleocin Cream 2 % Vaginal", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009338101", "ndc_label_name": "Cleocin in D5W Solution 300 MG/50ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009678001", "ndc_label_name": "Cleocin in D5W Solution 600 MG/50ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009989001", "ndc_label_name": "Cleocin in D5W Solution 900 MG/50ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009087021", "ndc_label_name": "Cleocin Phosphate Solution 300 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009030225", "ndc_label_name": "Cleocin Phosphate Solution 300 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009030202", "ndc_label_name": "Cleocin Phosphate Solution 300 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009087026", "ndc_label_name": "Cleocin Phosphate Solution 300 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009305102", "ndc_label_name": "Cleocin Phosphate Solution 300 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009305101", "ndc_label_name": "Cleocin Phosphate Solution 300 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009658201", "ndc_label_name": "Cleocin Phosphate Solution 300 MG/2ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009407303", "ndc_label_name": "Cleocin Phosphate Solution 600 MG/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009060204", "ndc_label_name": "Cleocin Phosphate Solution 600 MG/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009060225", "ndc_label_name": "Cleocin Phosphate Solution 600 MG/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009077520", "ndc_label_name": "Cleocin Phosphate Solution 600 MG/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009407304", "ndc_label_name": "Cleocin Phosphate Solution 600 MG/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009077526", "ndc_label_name": "Cleocin Phosphate Solution 600 MG/4ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009312401", "ndc_label_name": "Cleocin Phosphate Solution 600 MG/4ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009072809", "ndc_label_name": "Cleocin Phosphate Solution 9 GM/60ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009072805", "ndc_label_name": "Cleocin Phosphate Solution 9 GM/60ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009090125", "ndc_label_name": "Cleocin Phosphate Solution 900 MG/6ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009509506", "ndc_label_name": "Cleocin Phosphate Solution 900 MG/6ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009090106", "ndc_label_name": "Cleocin Phosphate Solution 900 MG/6ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009090211", "ndc_label_name": "Cleocin Phosphate SOLUTION 900 MG/6ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009090218", "ndc_label_name": "Cleocin Phosphate SOLUTION 900 MG/6ML INJECTION", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009509505", "ndc_label_name": "Cleocin Phosphate Solution 900 MG/6ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009344701", "ndc_label_name": "Cleocin Phosphate Solution 900 MG/6ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009766701", "ndc_label_name": "Cleocin Suppository 100 MG Vaginal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "52959027801", "ndc_label_name": "Cleocin-T Lotion 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00009332901", "ndc_label_name": "Cleocin-T LOTION 1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "98302000112", "ndc_label_name": "Clever Chek Auto-Code DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000111", "ndc_label_name": "Clever Chek Auto-Code System DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000102", "ndc_label_name": "Clever Chek Auto-Code Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000116", "ndc_label_name": "Clever Chek Auto-Code Voice DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000121", "ndc_label_name": "Clever Chek Auto-Code Voice DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000120", "ndc_label_name": "Clever Chek Auto-Code Voice STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000118", "ndc_label_name": "Clever Chek Auto-Code Voice STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000127", "ndc_label_name": "Clever Chek Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000115", "ndc_label_name": "Clever Chek Lancets", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000107", "ndc_label_name": "Clever Chek System KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000108", "ndc_label_name": "Clever Chek Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000129", "ndc_label_name": "Clever Choice Auto-Code System DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000128", "ndc_label_name": "Clever Choice Auto-Code Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "62850000025", "ndc_label_name": "Clever Choice BP Monitor/Arm Device", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000130", "ndc_label_name": "Clever Choice BP Monitor/Arm DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302014812", "ndc_label_name": "Clever Choice BP Monitor/Arm DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302014813", "ndc_label_name": "Clever Choice BP Monitor/Arm DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000142", "ndc_label_name": "Clever Choice BP Monitor/Wrist DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302001511", "ndc_label_name": "Clever Choice BP Monitor/Wrist DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302015225", "ndc_label_name": "Clever Choice BP Monitor/Wrist DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000109", "ndc_label_name": "Clever Choice Glucose Control Liquid High In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000110", "ndc_label_name": "Clever Choice Glucose Control Liquid Low In Vitro", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000139", "ndc_label_name": "Clever Choice Holding Chamber DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "98302000138", "ndc_label_name": "Clever Choice Holding Chamber DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "98302000143", "ndc_label_name": "Clever Choice Holding Chamber DEVICE", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50002086024", "ndc_label_name": "Clever Choice Humidifier", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302001424", "ndc_label_name": "Clever Choice Lancets 21G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302001422", "ndc_label_name": "Clever Choice Lancets 21G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302014204", "ndc_label_name": "Clever Choice Lancets 23G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302001421", "ndc_label_name": "Clever Choice Lancets 23G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302001420", "ndc_label_name": "Clever Choice Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302001407", "ndc_label_name": "Clever Choice Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302014200", "ndc_label_name": "Clever Choice Lancets 28G", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000180", "ndc_label_name": "Clever Choice Micro System KIT w/Device", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000170", "ndc_label_name": "Clever Choice Micro Test STRIP IN VITRO", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000131", "ndc_label_name": "Clever Choice Mini System DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302013942", "ndc_label_name": "Clever Choice No Coding STRIP In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000190", "ndc_label_name": "Clever Choice Talk System DEVICE", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "98302000191", "ndc_label_name": "Clever Choice Talk System STRIP In Vitro", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": true }, { "ndc": "10122061001", "ndc_label_name": "Cleviprex Emulsion 25 MG/50ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10122061010", "ndc_label_name": "Cleviprex Emulsion 25 MG/50ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10122061101", "ndc_label_name": "Cleviprex Emulsion 50 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "10122061110", "ndc_label_name": "Cleviprex Emulsion 50 MG/100ML Intravenous", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50419045404", "ndc_label_name": "Climara PATCH WEEKLY 0.025 MG/24HR TRANSDERMAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419045604", "ndc_label_name": "Climara PATCH WEEKLY 0.0375 MG/24HR TRANSDERMAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419045101", "ndc_label_name": "Climara PATCH WEEKLY 0.05 MG/24HR TRANSDERMAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419045104", "ndc_label_name": "Climara PATCH WEEKLY 0.05 MG/24HR TRANSDERMAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419045904", "ndc_label_name": "Climara PATCH WEEKLY 0.06 MG/24HR TRANSDERMAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419045304", "ndc_label_name": "Climara PATCH WEEKLY 0.075 MG/24HR TRANSDERMAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419045204", "ndc_label_name": "Climara PATCH WEEKLY 0.1 MG/24HR TRANSDERMAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419045201", "ndc_label_name": "Climara PATCH WEEKLY 0.1 MG/24HR TRANSDERMAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "50419049104", "ndc_label_name": "Climara Pro PATCH WEEKLY 0.045-0.015 MG/DAY TRANSDERMAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "54868557000", "ndc_label_name": "Climara Pro PATCH WEEKLY 0.045-0.015 MG/DAY TRANSDERMAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": true, "otc": false }, { "ndc": "69101071501", "ndc_label_name": "CLIN Single Use Kit 300 MG/2ML Injection", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43538017360", "ndc_label_name": "Clindacin ETZ KIT 1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43538017260", "ndc_label_name": "Clindacin ETZ Swab 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43538017910", "ndc_label_name": "Clindacin Foam 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43538017169", "ndc_label_name": "Clindacin Pac Kit 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "43538017069", "ndc_label_name": "Clindacin-P Swab 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16781046275", "ndc_label_name": "Clindagel Gel 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268018015", "ndc_label_name": "Clindamycin HCl Capsule 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42292001820", "ndc_label_name": "Clindamycin HCl Capsule 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591570801", "ndc_label_name": "Clindamycin HCl Capsule 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713317101", "ndc_label_name": "Clindamycin HCl Capsule 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527138201", "ndc_label_name": "Clindamycin HCl Capsule 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42292001801", "ndc_label_name": "Clindamycin HCl Capsule 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268018011", "ndc_label_name": "Clindamycin HCl Capsule 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00904595961", "ndc_label_name": "Clindamycin HCl CAPSULE 150 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63739005910", "ndc_label_name": "Clindamycin HCl Capsule 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42571025101", "ndc_label_name": "Clindamycin HCl Capsule 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084024311", "ndc_label_name": "Clindamycin HCl CAPSULE 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762332801", "ndc_label_name": "Clindamycin HCl CAPSULE 150 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304069205", "ndc_label_name": "Clindamycin HCl CAPSULE 150 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304069201", "ndc_label_name": "Clindamycin HCl CAPSULE 150 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862018501", "ndc_label_name": "Clindamycin HCl CAPSULE 150 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862018505", "ndc_label_name": "Clindamycin HCl CAPSULE 150 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084024301", "ndc_label_name": "Clindamycin HCl CAPSULE 150 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268018111", "ndc_label_name": "Clindamycin HCl Capsule 300 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762501002", "ndc_label_name": "Clindamycin HCl CAPSULE 300 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591293201", "ndc_label_name": "Clindamycin HCl Capsule 300 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527138301", "ndc_label_name": "Clindamycin HCl Capsule 300 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "63304069301", "ndc_label_name": "Clindamycin HCl CAPSULE 300 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527138302", "ndc_label_name": "Clindamycin HCl Capsule 300 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42571025201", "ndc_label_name": "Clindamycin HCl Capsule 300 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00713525601", "ndc_label_name": "Clindamycin HCl Capsule 300 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084024401", "ndc_label_name": "Clindamycin HCl CAPSULE 300 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50268018115", "ndc_label_name": "Clindamycin HCl Capsule 300 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68084024411", "ndc_label_name": "Clindamycin HCl CAPSULE 300 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862018601", "ndc_label_name": "Clindamycin HCl CAPSULE 300 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762501001", "ndc_label_name": "Clindamycin HCl CAPSULE 300 MG ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42571025001", "ndc_label_name": "Clindamycin HCl Capsule 75 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00527138104", "ndc_label_name": "Clindamycin HCl Capsule 75 MG Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00574012901", "ndc_label_name": "Clindamycin Palmitate HCl SOLUTION RECONSTITUTED 75 MG/5ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65162046819", "ndc_label_name": "Clindamycin Palmitate HCl SOLUTION RECONSTITUTED 75 MG/5ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714048301", "ndc_label_name": "Clindamycin Palmitate HCl SOLUTION RECONSTITUTED 75 MG/5ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23155060351", "ndc_label_name": "Clindamycin Palmitate HCl Solution Reconstituted 75 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762001601", "ndc_label_name": "Clindamycin Palmitate HCl Solution Reconstituted 75 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "64980051110", "ndc_label_name": "Clindamycin Palmitate HCl Solution Reconstituted 75 MG/5ML Oral", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "65862059601", "ndc_label_name": "Clindamycin Palmitate HCl SOLUTION RECONSTITUTED 75 MG/5ML ORAL", "drug_tier": "Tier 3", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378868850", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802050701", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378868835", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox GEL 1-5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378868854", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox GEL 1-5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781726368", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802051003", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00378868852", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462048624", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781729146", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672138102", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781728750", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714098425", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802050901", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672138106", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714098450", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462085924", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "58118996305", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox GEL 1-5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23490193601", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox GEL 1-5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462048627", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462085927", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68462048619", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802050703", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802050702", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox GEL 1-5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682019025", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682019035", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802050704", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox GEL 1-5 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672138104", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672138105", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682019050", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1-5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802059701", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-2.5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00591391668", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-2.5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672136703", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-2.5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682013250", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-2.5 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "68682013350", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-3.75 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672140304", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-3.75 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802038301", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-3.75 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "72162241902", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-3.75 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "70710144504", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672136606", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox GEL 1.2-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802073684", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox GEL 1.2-5 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00781716119", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "66993094945", "ndc_label_name": "Clindamycin Phos-Benzoyl Perox Gel 1.2-5 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "54569644600", "ndc_label_name": "Clindamycin Phosphate Cream 2 % Vaginal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090138300", "ndc_label_name": "Clindamycin Phosphate Cream 2 % Vaginal", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168027740", "ndc_label_name": "Clindamycin Phosphate CREAM 2 % VAGINAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "59762500901", "ndc_label_name": "Clindamycin Phosphate CREAM 2 % VAGINAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802066032", "ndc_label_name": "Clindamycin Phosphate FOAM 1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "45802066033", "ndc_label_name": "Clindamycin Phosphate FOAM 1 % EXTERNAL", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168020230", "ndc_label_name": "Clindamycin Phosphate GEL 1 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "23490533401", "ndc_label_name": "Clindamycin Phosphate GEL 1 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "50090595800", "ndc_label_name": "Clindamycin Phosphate Gel 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714016101", "ndc_label_name": "Clindamycin Phosphate Gel 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "16714016102", "ndc_label_name": "Clindamycin Phosphate Gel 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "42254017330", "ndc_label_name": "Clindamycin Phosphate GEL 1 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "33261042201", "ndc_label_name": "Clindamycin Phosphate Gel 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "69238203107", "ndc_label_name": "Clindamycin Phosphate Gel 1 % External", "drug_tier": "Tier 2", "prior_authorization": true, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "00168020260", "ndc_label_name": "Clindamycin Phosphate GEL 1 % EXTERNAL", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false }, { "ndc": "51672139902", "ndc_label_name": "Clindamycin Phosphate Gel 1 % External", "drug_tier": "Tier 1", "prior_authorization": false, "step_therapy": false, "quantity_limit": false, "otc": false